Cancer prehabilitation in Scotland: 2025 survey findings report

7. Discussion and recommendations

This analysis provides insights that can be considered by CPOG and delivery partners to shape further programme development and implementation of prehabilitation activities. Discussion and recommendations have been set out around five key themes. Implications for progress are considered in relation to relevant Actions in the Cancer Action Plan, and areas for follow-up conversations with staff are highlighted where further insights and analysis would be beneficial.

Further action to increase awareness

Awareness of the ‘Key Principles’ of prehabilitation remains uneven, with two fifths reporting high levels of awareness (41%) and a similar proportion (38%) reporting low awareness. Some respondents described successful awareness-raising activities having taken place recently in their local area, and the positive impact these activities have had on prehabilitation referrals. Overall results suggest that further action is needed to raise awareness of what the Key Principles of prehabilitation constitute, and the value of prehabilitation – ensuring this is understood across all professional groups – to deliver a consistent message to people with cancer so that they receive support earlier in their cancer journey. In light of these findings, further work with NHS Education for Scotland would be beneficial to support Action 51 to ensure educational tools that support the development and delivery of high quality prehabilitation services are available and accessible to all.

Relatedly, the use of the Prehab and Me website was reported by around one in five respondents (19%), with a lack of awareness being the primary barrier. Those who did use the website found it valuable both for signposting to patients and for using for their own professional learning. More promotion of this resource is recommended across professional groups and Cancer Networks.

Respondents suggested including prehabilitation in professional or vocational online training programmes, which could present a mechanism for boosting awareness of existing online resources and the nutrition and psychological support Frameworks. While the 2025 survey suggests there is more nutrition screening and dietetic involvement compared with 2022, and follow-up conversations with staff are recommended for more conclusive insights about the modes of support being offered, further awareness-raising would support Action 49 to improve understanding of the role of nutritional care and to aid implementation of the Nutrition Framework to assess nutritional needs. Similarly, further work to increase awareness and promote resources amongst staff working with people affected by cancer would support progress with Action 106 to implement and apply the Psychological Therapies and Support Framework in practice. In turn, sharing relevant training and educational resources will support Action 51 to ensure appropriate tools are available and accessible to all staff to support the development and delivery of high quality prehabilitation services. It is advised that future surveys ask about the actual use of resources as well as awareness.

Respondents in this survey expressed a desire to know what local prehabilitation activities are available and how to access them. Uncertainty around workforce composition also highlights the need to ensure potential referrers understand the make-up of prehabilitation services and who is delivering them. With a strategic shift in the SG’s Service Renewal Framework to greater provision of health and social care in community settings, staying up to date with what activities are available locally and where they are located may become even more important as health services may be increasingly delivered outside of hospitals. Respondents proposed ways of disseminating information, such as hospital newsletters and emails, talks, workshops and team meetings. Extending dissemination beyond organisational boundaries, including the Third Sector, will be relevant in the context of Service Renewal, to increase awareness and signposting to services across sectors, and to support collaboration and coordination of prehabilitation activities.

Learning from pilot projects and partnerships

The overall coverage of prehabilitation activities reported by respondents in 2025 remains similar to 2022. To reduce unwarranted variation in access to prehabilitation nationally, there is a clear need to expand coverage to achieve the goal of nationwide coverage of universal prehabilitation (Action 48) and to deliver targeted and specialist interventions also. Respondents highlighted concerns about insecure funding and existing pressures on the cancer care workforce. It may be valuable to share learning from areas where collaboration is working well to deliver multi-modal prehabilitation, including timely screening and referral. This could include sharing learning about how MDTs are structured, how care is coordinated, as well as how cross-sector partnerships are built and sustained. It could also include sharing learning between Senior Leaders/ Service Managers about the ways in which they are actively embedding and scaling up prehabilitation in pathways of care, an effort that would require senior buy-in and leadership, a key enabler highlighted in the 2023 report. Cross-sector collaboration was highlighted positively in the 2025 survey, reflecting progress towards Actions 48 and 50 in terms of providers working together to deliver a universal programme of activities similar to the offer in Maggie’s Centres.

Service integration and partnership for prehabilitation is echoed by Giles and Commins (2019) who suggest collaboration at a local level and peer support capacity as ways in which prehabilitation can be delivered in the context of a stretched NHS workforce. Respondents here suggested introducing or strengthening MDTs, automatic referrals, coordinator roles and prehabilitation clinics as operational examples of staff working together to provide timely pre-treatment interventions, in ways that do not place additional burden on people who have recently been diagnosed with cancer. Establishing a forum where delivery partners can share learning from pilot projects would be beneficial to foster collaboration and partnership working across services to support wider adoption of prehabilitation. While local learning around sustainability is valuable, particularly from areas where projects have been scaled up successfully, it may be appropriate to review any assumptions relating to investment that underpin activities to deliver nationwide coverage. Consideration of this issue is important when non-recurring funding presents a substantial barrier to progress to expand services.

Actions to improve access to prehabilitation

While video consultations were acknowledged to enable more remote connections, accessibility was a key issue in survey responses. Similar groups were identified as facing specific barriers to accessing prehabilitation as in 2022, including people living in remote and rural areas, and those without a smart phone, with low literacy, or with comorbidities. This finding likely reflects systemic inequalities in healthcare. It also suggests that a ‘one size fits all’ mode of prehabilitation delivery is unlikely to meet the needs of people with cancer, and that maintaining universal access while also addressing specific access needs may be most appropriate. A form of proportional universalism is already in place through the targeting of prehabilitation via screening, however, targeting of resources should be considered in the commissioning of activities with the wider determinants of health and cancer prevention in mind.

While the proportion of respondents reporting permanent funding was higher than 2022, 14% up from 2%, respondents emphasised that the funding landscape for prehabilitation is complex, with different types of funding at times linked to specific cancers. People with Stage 1 or Stage 2 cancers, receiving non-surgical treatment and those receiving palliative care were highlighted as facing inequity of care due to the scope of prehabilitation activities in some areas. This implies that it may be beneficial to provide NHS Boards with guidance on aligning resources to support more equitable implementation across cancers, cancer stages, and care or treatment types, or to consider whether there should be prioritisation.

One in four respondents (25%) indicated local plans to introduce or expand prehabilitation activities. Support to expand prehabilitation activities may be necessary if equitable access across Scotland remains an ambition of the second Cancer Action Plan. Ensuring sustainable funding models are in place to support activities will be important if the offer of prehabilitation is to be expanded without unwarranted variation across areas and groups. Some respondents also described moving to digital technologies for offering support, while others mentioned increased capacity for face-to-face support. Stewart et al. 2025 note that consulting with patients in the design and delivery of prehabilitation is key to providing truly person-centred care. This includes assessing digital exclusion and how to mitigate this for vulnerable groups when offering community-based or digital care.

In line with the Service Renewal Framework, knowledge, tools and resources are needed to support digital inclusion, with an emphasis on innovation and a ‘digital first’ mindset for service development. Respondents highlighted interpersonal factors that are important for engaging people in prehabilitation, including ensuring conversations about lifestyle are sensitive so as not to be perceived as ‘blaming’ the person with cancer. They also emphasised avoiding overwhelming people with too much information at diagnosis, or overburdening by appointments, especially for those living at a distance from services. Therefore, consideration should be given to how inclusion and person-centredness will be central to new prehabilitation activities, particularly those using digital technologies.

Evidencing impact on patient outcomes

Responses continue to highlight a variety of approaches to monitoring and outcome measurement. One in three respondents with local prehabilitation activities reported using outcome measurements, a level which is unchanged from 2022, and findings reflected a general uncertainty about how monitoring was undertaken. Regarding positive developments, there was an increase in the proportion agreeing that local prehabilitation activities use validated tools for individual assessment, care planning and outcomes measurement in 2025, compared to 2022. In addition, a few respondents described digital recording of outcomes, tests of change, audit or process evaluation underway in their local area. Further progress in this area would support Action 50 to embed successful prehabilitation approaches in management guidelines and pathways of care, whilst also evidencing impact of outcomes.

A community of practice or knowledge sharing activities specifically around evidencing impact are recommended to share good practice and strengthen robust approaches to measurement, which may contribute to demonstrating value and cost effectiveness (Sout et al. 2022). Guidance around collecting experience data, given the uncertainty in survey responses around this aspect of measurement, would also be advised to drive improvements in services. These recommendations build on those presented in the 2023 report, highlighting national guidance on the measurement of outcomes, and core dataset to support monitoring and evaluation.

Integration with rehabilitation

In light of responses emphasising the need to integrate prehabilitation and rehabilitation more fully along the continuum of care, it is recommended that this finding is tabled for discussion at the National Rehabilitation Network meeting to agree on any required actions. This would include identifying and sharing good practice, in particular to inform staff about pathways and resources available, and identifying where any improvements may be needed to support progress with Actions 70, 71 and 72 in relation to rehabilitation services.

Follow-up conversations with staff

There were some areas within survey results that showed an unclear or slightly contradictory picture. For example, unlike previous survey findings which indicate that physical activity is the most common component of prehabilitation in Scotland (Provan et al. 2022), this survey suggests that screening and staffing for nutritional support is presently more common practice compared to the other two modes. Given the limitations around comparison over survey years due to sampling, it would be useful to explore any underlying reasons for these patterns of response: whether the levels of psychological and physical activity interventions or screening are declining, or to what extent this shift in response reflects changes in the occupational profile of respondents and their awareness of practice (and their knowledge of different parts of the system) between surveys.

In-depth exploration of perspectives on multi-modal staffing and screening practices would be beneficial to understand progress relating to Actions 49 and 106 to implement nutritional and psychological support, and to provide further insights into any barriers or enablers to embedding these Frameworks more fully in cancer pathways. Follow-up conversations would also bring additional insights in relation to funding models, including consideration of resource allocation trade-offs and learning around how to sustain activities as pilot projects come to an end. Additionally, follow-up conversations would be beneficial to explore the integration of prehabilitation and rehabilitation services in more depth.

For future surveys, it would be informative to ask staff about their use (as well as awareness) of specific professional frameworks related to prehabilitation, for example, the Nutrition Framework and the Psychological Therapies and Support Framework, in addition to the resources that they use in practice, including the Prehab and Me website. This would help build a picture of current forms of skills development and support needed to build competence and capacity to deliver multi-modal prehabilitation.