Cancer Prehabilitation: Staff perspectives on implementation

Key Findings – Staff views on future areas of focus

Discussions across focus groups covered what participants felt the areas of future focus should be. The idea of ‘quick wins’ was introduced by facilitators, as low effort, high impact actions that are aligned with longer-term goals, as shown in the diagram below. This was differentiated from ‘quick fixes’ which may superficially solve an issue but do not address underlying problems. In debriefs following the focus groups, facilitators observed that participants took their time before responding to these questions and provided considered responses.

From the suggestions that staff provided throughout focus groups, potential ‘quick wins’ have been identified in the analysis. These include:

• Workshops to bring together delivery partners across sectors (NHS, third sector, independent sector and local authorities), to map out local and regional prehabilitation services, identify under and over utilisation and clarify roles and responsibilities in the pathway.
• Offering a hybrid mix of delivery models including online and in-person interventions to cater for diverse patient preferences and locations, using local health and sports centres and community buildings to reduce travel barriers.
• Increased use of visual aids and prompts in clinics and waiting rooms, such as video adverts, to raise awareness of what cancer prehabilitation is and make the public more familiar with the term.^[2]
• Centralised information or repositories about what prehabilitation activities are available locally that can be filtered by cancer type and geographical area.^[3]
• Making information about prehabilitation and services available in multiple languages and formats to cater for diverse cultural and language needs.
• Upskilling prehabilitation staff in behaviour change to improve skills around patient engagement.
• Automatic free passes to local gyms as part of universal prehabilitation.
• Linking with the National Physical Activity Pathway^[20].
• Collaborating with other teams and working across tumour groups.

Participants also described ways in which they are currently working, or have worked, that could be considered as maximising capacity:

• Integrating the third sector and local authorities more formally into prehabilitation pathways, for example, through shared steering groups, or embedding specialist staff in non-NHS settings to provide targeted support.
• Scaling up interventions through offering online sessions, group sessions, peer support or (for universal prehabilitation) volunteer-led interventions, while acknowledging that some people require individualised and bespoke support.
• Exploring navigator or healthcare support roles as a consistent person to help patients navigate the prehabilitation pathway, assist with screening and referrals, support with equity of access and reduce some of the administrative burden on clinical staff.
• Circulating regular updates through teams on prehabilitation activities available and dates for prehabilitation support sessions.
• Producing leaflets with details of the prehabilitation website, a list of support services, and QR codes for screening or physical activity videos.
• Third sector outreach events to medical students on cancer prehabilitation to foster a consistent message and build connections between sectors.
• Making prehabilitation interventions more accessible through diversifying locations and creating ‘shorter’ online sessions of 20-30 minutes.
• Signposting to banks and financial institutions to improve digital skills and widen online access to prehabilitation resources.

Participants wished to emphasise that over and above ‘quick wins’, there are systemic, long-term and complex challenges that need to be addressed with more effort and resource if the pre-treatment ambition is to be realised. Suggestions for longer term areas of focus were:

• Automatic referrals to universal prehabilitation services, unless a patient explicitly opts out, so that prehabilitation is a standard and early part of the pathway.
• Creating a prehabilitation-related metric, such as a Quality Performance Indicator (QPI), to encourage a consistent message from health care professionals about prehabilitation as an integral part of the cancer pathway and not an add-on.
• Securing dedicated resource for establishing a prehabilitation service, to help move healthcare input from a reactive to proactive model.
• Workforce planning using screening data within a strategic needs assessment to determine the number of specialist staff needed for prehabilitation services locally.
• Developing a stronger evidence base to demonstrate the benefits of prehabilitation (for example, a robust cost benefit analysis), and help secure commitment from strategic decision makers.
• Related to strategic commitment and investment, standardised patient reported outcome measures to allow consistent data collection to demonstrate benefit.
• Improved IT infrastructure and resource to manage patients’ baseline and outcomes data, for example, patient held records accessible to the patient and staff across sectors.

In summary, suggestions can be grouped by a number of themes for future focus such as ways to improve communication and trust between partners, ways to enhance education and awareness of prehabilitation (amongst prehabilitation staff and the wider public) and improve knowledge of services available. Suggestions relate to ways of securing strategic buy in and funding for sustainable services through better use of data, enhancing accessibility and equity of prehabilitation, workforce development through training, and investment in systems to make systematic recording of patient screening, assessment and outcomes data easier.

It is important to note that the suggestions above reflect the views of participants, categorised by an analyst. Literature surrounding the potential effectiveness, feasibility and practicality of the ideas are discussed in the section below, in order to inform recommendations. Where relevant resources may already be available, these are signposted in the discussion below, and their potential considered.