This survey showed very high recognition amongst respondents of the importance of both prehabilitation and rehabilitation in improving people's experience of cancer treatment and outcomes. This suggests an appetite in principle to develop and improve local prehabilitation services. Knowledge and understanding of what this would involve in practice appeared lower, as reflected by only two fifths of respondents with high awareness of the 'Key Principles'. There would be value in further promotion of these principles to those who would be involved in future commissioning, planning or delivery of local prehabilitation services.
At the time of the survey around half of respondents had local prehabilitation services. During the COVID-19 pandemic, services had been scaled back or stopped but were now resuming or starting. The pandemic experience of delivering some services via phone or video had informed the resumption of some services using blended delivery modes. This approach offers an opportunity to improve people's access to services, but with the recognition that video appointments are not appropriate for everyone.
Staffing and funding for prehabilitation, and broader pressures on health services, were identified as key barriers to developing and sustaining prehabilitation services. Since 2019 there has been a notable decrease in permanent funding and increase in temporary funding for services. The need for designated staffing across roles and for dedicated and permanent funding was emphasised in the survey. Respondents indicated that such resourcing was necessary to enable staff to dedicate time to prehabilitation. While the broader environment is challenging, these issues would need to be considered if current or future prehabilitation services are to attract and retain staff and become part of core services.
Survey respondents identified improvements needed in prehabilitation service delivery and pathways. The need for timelier referral, earlier patient screening, identification and offer of prehabilitation, and appropriate referral to universal, targeted and specialist services, were all emphasised. It was acknowledged that interventions needed to include and better link together all three prehabilitation modes. The need for prehabilitation to be part of a seamless patient pathway through to rehabilitation was highlighted. Some respondents commented that guidance for local services would be useful. This view may be linked to low levels of awareness of the principles of prehabilitation, which further promotion would address. However, this finding might also suggest that sharing good practice on how to implement and deliver prehabilitation could help embed the principles in practice. National guidance could be developed to set out the core elements and characteristics of local services, and how to integrate multimodal interventions, in order to alert staff to these issues and support local service development and delivery. These improvements could also be supported through the Single Point of Contact approach, pathway navigators and cancer support workers.
The need for senior leadership buy-in and support for local prehabilitation in principle was highlighted. This would set the tone for their staff and encourage them to integrate prehabilitation into local pathways. It could also inform local discussions about the provision of more secure and sustainable long-term staffing and funding for services.
Survey respondents identified some specific patient groups at risk of inequitable access to services. These included people living in remote and rural areas and on islands, those in tumour groups without prehabilitation services, and those experiencing socio-economic inequalities. Local services should address potential barriers to access for people in those groups, and ensure that the mode of service delivery maximises their access and promotes the inclusion of all.
MDT engagement, good communication between service providers and collaborative partnership working with third sector projects were all viewed as important enablers of effective prehabilitation services. Any future national guidance could specify in more detail the different staff roles and organisations which should be involved in local prehabilitation services, including third sector initiatives such as those delivered by Maggie's and Macmillan Cancer Support. This would support the suggestion above to develop further guidance for service development and implementation.
The survey showed that awareness of local prehabilitation service monitoring was limited, and that local services used a variety of approaches to measure outcomes. More systematic monitoring and outcome measurement could generate evidence of the benefits of prehabilitation for patients, help engage local service providers and patients themselves, and make the case for investment in local services. National guidance could include advice and templates for local monitoring and outcome measurement. With the aim to roll out prehabilitation across Scotland, consideration of the development of a national core dataset would be useful to support monitoring and evaluation of prehabilitation services and their impact on patient outcomes.
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