Cancer Prehabilitation: Staff perspectives on implementation

Executive Summary

Purpose

Cancer prehabilitation (‘prehab’) is support delivered before definitive cancer treatment, and includes physical activity/exercise, nutrition and psychological support. The Scottish Government’s 10-year Cancer Strategy^[1] sets out an ambition that every person diagnosed with cancer in Scotland is provided with timely, effective and individualised care to best prepare them for treatment. Prehabilitation forms part of a continuum with cancer rehabilitation, to support an individual’s recovery before, during and after treatment.

This report presents findings from follow‑up focus groups to a national survey of prehabilitation staff in Scotland (2025)^[2]. The survey explored prehabilitation staff awareness of cancer prehabilitation, local activities, and views on ways to improve pathways for optimising patients for treatment. The aim of focus groups was to gather in-depth insights into survey results, to better understand the context in which prehabilitation is being implemented. Together, the survey and focus groups help describe progress against the Cancer Strategy (2023-2033) and, alongside wider evidence, shape the actions in the second Cancer Action Plan.

Approach

• Seven online focus groups were conducted with 32 prehabilitation staff, working in the NHS, third sector, leisure/local authority or other organisations. These took place in December 2025 and January 2026.
• Participants were recruited primarily from 2025 survey respondents who consented to be recontacted. In addition, targeted outreach to three professional bodies relevant to cancer prehabilitation was undertaken to improve representation of different roles and sectors.
• Focus groups lasted 60 minutes and were jointly facilitated by a Scottish Government social researcher and Macmillan National Improvement Advisor for Cancer Prehabilitation using one of two topic guides, focused on either ‘Pathways and partnerships’ or ‘Service renewal, redesign and sustainability’. Participants self-selected their preferred focus group discussion topic.
• Focus groups were transcribed via Microsoft Teams, and anonymised, coded and thematically analysed using software MaxQDA, with a second researcher coding a subset of transcripts and the use of AI-Assist functions for quality assurance.
• Findings are presented as six interlinked themes, and participants’ ideas for areas of future focus have been included to guide the development of actions to support ongoing national implementation of prehabilitation services.

It is important to note that the sample is not representative of all prehabilitation staff and may over‑reflect views of those motivated to engage in evaluation activity, and under-represent some professional groups and perspectives on prehabilitation. Group dynamics and winter pressures may also have influenced participation and responses, and therefore findings.

Key Findings

Six interlinked themes capture the context of cancer prehabilitation as described by staff, and factors that are helping or hindering implementation:

1. The role, framing and messaging around prehabilitation

A recurring issue was that cancer prehabilitation is frequently perceived as an ‘add‑on’ rather than a core component of treatment, including at strategic levels. Participants emphasised that consistent, clear messaging, especially from influential clinicians, can shape patient engagement in prehabilitation. There was strong support for simple, jargon‑free information to improve public awareness, so that patients are not encountering prehab as a new concept at the emotionally challenging time of cancer diagnosis.

2. Strategic commitment and coordination at senior leadership levels

Participants described the provision of prehabilitation as often shaped by time-limited ‘projects’ rather than embedded pathways, rendering these less sustainable. They felt that a strong business case could support NHS Boards to invest in infrastructure and funding for prehabilitation. Several proposed prehabilitation metrics to increase visibly and strategic focus, while recognising practical challenges in defining an appropriate metric.

3. Referrals onto, and touchpoints along, the pathway

Participants emphasised informed choice, through accessible information and through a flexible, ‘menu‑like’ offer of prehab to match different needs and preferences. Providing information alone was felt to be insufficient for prehabilitation uptake, and patient engagement was linked to levels of internal motivation and health literacy at diagnosis. Some suggested multiple touchpoints along the pathway so that patients can engage when they are more psychologically ready, and wider use of behaviour change training for staff.

4. Collaboration – awareness, trust and working across organisations

Where collaboration worked well in delivering prehabilitation, it was often described as facilitated by specific ‘champions’ who built cross-sector relationships, convened partnerships, and created awareness-raising opportunities. However, low awareness about, and trust between, NHS and non‑NHS organisations was felt in some cases to impact referral patterns and equitable partnership. Participants identified facilitators of cross-sector working, including bringing organisations together to clarify roles and responsibilities at each stage of the prehabilitation pathway; improving how data is shared between organisations; and having key information about local services available in one place.

5. Reducing barriers and promoting equity of access

Equity of access to prehabilitation support was a prominent concern for participants. Participants identified barriers such as digital poverty and digital literacy, distance/rurality and transport, time constraints due to patients’ work patterns, affordability, language, levels of immunocompromise, and health literacy. The importance of hybrid delivery models and care closer to home, such as in community venues, or online options was emphasised. Participants also highlighted the need for practical support with transport and language translation to avoid widening existing inequalities.

6. Planning and resourcing in services

Staff described a paradox in which some prehabilitation activities were under‑utilised while others were overstretched, and emphasised the importance of data in optimising system capacity. They outlined a desire for better screening and assessment data to inform workforce planning and strategic needs assessment, to shift resourcing form being based on ‘what we have’ to ‘what the population needs’. Participants highlighted examples of workforce constraints impacting on timely care. Navigators, such as within the Single Point of Contact initiative, were seen as potentially beneficial to support prehabilitation screening and referral, provided these roles are clearly defined regarding responsibilities and appropriate skills.

Considerations for the next Cancer Action Plan

Based on staff persepectives shared, several recommendations are made to support the implementation of prehabilitation in a way that could improve the reach and quality of services. In summary terms, these are:

• Review and update cancer pathways so that prehabilitation is the default option for patients (opt-out)
• Create prompts for different healthcare professions to support the delivery of prehabilitation
• Build familiarity and trust between delivery partners
• Pilot specific support to improve access and uptake among groups who experience barriers to universal prehabilitation
• Develop a minimum data set for cancer prehabilitation to evidence impact
• Propose cancer prehabilitation as a candidate for the next phase of the Digital Front Door roll out, for example, as a portal for screening, assessment and outcomes data
• Clarify roles and responsibilities of prehabilitation workforce