Cancer Prehabilitation: Staff perspectives on implementation

Discussion

How do staff think pathways and partnerships should ideally function?

Almost a decade ago, Macmillan’s Prehabilitation Evidence and Insight Review^[21] (2017) identified a number of key questions that were evidence gaps at the time, including ‘who is best placed to provide prehabilitation?’, and ‘who can realistically provide prehabilitation?’ Follow up Principles and guidance^[8] co-produced by Macmillan, the Royal College of Anaesthetists, the National Institute for Health Research Cancer and the Nutrition Collaboration, set out a framework for registered and unregistered professionals involved in multi-disciplinary team working to deliver prehabilitation. Macmillan guidance updated in 2025^[3] promotes prehabilitation as means to enable people with cancer to prepare for treatment by encouraging healthy behaviours and needs‑based exercise, nutrition, and psychological support. Prehabilitation sits within a continuum of rehabilitation and aims to empower patients to build resilience to cancer and its treatment and to improve long‑term health.

The focus groups conducted for this report shed light from staff perspectives on the question of ‘who can realistically provide prehabilitation?’. As reflected in the principles and guidance, focus group data outlines that the delivery of prehabilitation spans across a number of care professionals and settings. Clinical nurse specialists (CNS) were viewed as crucial, given their close contact with patients at diagnosis. However, CNS were viewed as a stretched resource. Navigators and healthcare support workers, where they exist in services, were described as providing support with patient-related and clinical-based administration, and in doing so, supporting sustainability of services and promoting equity of access. Allied health professionals were considered critical for delivering specialist prehabilitation, with some calls to embed allied health professionals in services instead of having to refer out. Consultants and oncologists were viewed as having an important role in endorsing and providing a consistent message around the benefits of prehabilitation, with staff reflecting that this message should be promoted by all in these roles rather than the responsibility falling on a small number of oncologists or surgeons with a special interest.

The key role of the third and independent sectors as providers of universal prehabilitation was emphasised by staff, with emotional support and support with transport seen as well placed here. The NHS and the local authority leisure sector were described as important providers of physical activity support. Specialist nutritional and psychological support were viewed as being within the domain of the NHS. In debriefs, focus group facilitators observed constructive dialogue between professionals from different sectors and reflected on how clear the sense of a shared goal was, for improving the lives of people with cancer. The Health and Social Care Service Renewal Framework^[13] (SRF) emphasises that the voluntary sector, community-based organisations, carers (paid and unpaid), social care services, social workers and primary and community care are all central to the local delivery of prevention and early intervention activities.

The SRF also notes that shifting resource to community settings will be a necessary step to allow for the effective delivery of care, in this case pre-treatment care, as close to patients’ homes as possible. This is likely to be relevant to cancer prehabilitation and aligns with one participant’s suggestion of time-limited transitional funding to establish a prehabilitation service while maintaining current activities to support a shift in healthcare input from a reactive to a proactive model. While early intervention may require increased resource earlier in the pathway, such an approach may help to reduce the need for reactive complex care later.

Focus group findings suggest a strong willingness and motivation among staff for greater cross‑sector collaboration in the delivery of prehabilitation. However, they also indicate that the appropriate data‑sharing infrastructure is not often in place to support smooth collaborative working. In addition, variable awareness of, and attitudes towards, non‑NHS delivery partners may contribute to fragmentation. Wider evidence on partnership working from the Healthy Communities Together programme^[22] highlights that the alignment of values and a shared sense of purpose are key enablers of motivation in working across statutory and voluntary sectors, alongside the need for intentional governance and convening structures that are appropriate to the local context. For example, for cancer prehabilitation, these governance and convening structures could practically include an information governance and data sharing agreement, a shared competency framework and/or a data feedback loop relevant to the local context to ensure trust and awareness. This will require leadership to develop such agreements, and a willingness to collaborate across sectors, bringing together all the skills, experience and assets that are available across the system.

What are the barriers to effective pathways and partnerships?

There were a number of barriers raised by participants felt to impact upon effective pathways and partnerships. These are described in Key Findings, and are summarised in the table below as barriers facing patients, staff and systems. They point to constraints that may be at play in the implementation of cancer prehabilitation, while also highlighting areas for actions to improve pathways and strengthen partnerships at different levels.

A review of international evidence on the implementation of cancer prehabilitation^[24] identifies key barriers including patient engagement, communication, workforce planning, and constrained staff capacity. These barriers were also evident in the focus group findings. However, issues relating to attitudes towards prehabilitation providers, levels of trust between partners, and the ease of data sharing were more strongly emphasised in the focus groups than in the reviewed literature. Knowledge of, and confidence in, delivery partners therefore emerges as an important issue for cancer prehabilitation and the second Cancer Action Plan. An important next step for the strategy would be to support partners across all levels (local, regional and national) to encourage communication and increased trust in partnerships. This include exploring leadership resources available, such as those compiled by the Local Government Association^[25], aimed to help middle leaders address power imbalances in partnerships, collaboration and integration within cross‑sector partnerships.

The review also suggests that, internationally, the main barriers to the implementation of cancer prehabilitation are: a lack of national policy support, limited resources, and insufficient evidence on the long-term effectiveness and cost-efficiency of prehabilitation. In Scotland, national policy provides clear support for the implementation of prehabilitation, as outlined in the Cancer Strategy 2023-2033^[1]. As part of this, the Cancer Action Plan (2023-2026)^[7] set out to develop a partnership to explore digital innovation (Action 47), nationally roll out face-to-face universal prehabilitation through Maggie’s and other providers (Action 48), develop tools to aid the assessment of nutritional needs of people affected by cancer (Action 49), work with stakeholders to test and embed successful approaches to prehabilitation (Action 50), and work with the NES to make available tools that support the delivery of high quality prehabilitation services (Action 51). These actions have been supported by the Cancer Prehabilitation Oversight Group. While national policy has been in place, limited resources and a ‘good business case’ on the long-term effectiveness for prehabilitation remain relevant areas to address.

Finally, the review authors recommend first addressing organisational barriers before addressing patient barriers in the implementation of cancer prehabilitation. As highlighted in a recent evidence review of ethnic and racialised inequalities in cancer services^[26], organisational and patient barriers are not separate, and what can present as a patient barrier can reflect structural inequalities within the wider health care system. A focus group participant highlighted that video information materials were largely available in English. Although YouTube’s captioning tools allow captions on Prehab and Me videos to be auto‑translated into multiple languages, further action may be required to make sure staff are aware of translation functions and use them when appropriate. More widely to improve access to cancer prehabilitation, a two-pronged approach may be needed: to improve overall service availability through enhanced strategic commitment, and resourcing, alongside actions to address existing inequities of access, to prevent the widening of inequalities between those who are more and less able or motivated to participate in prehabilitation. This may include, for example, piloting specific support to those who currently are known to have low uptake of universal prehabilitation.

What does this mean for the next Cancer Action Plan?

Focus groups helped to supplement findings from the 2025 prehabilitation survey by providing insights from a staff perspective on the context in which prehabilitation is being implemented in Scotland. They also shed some light on developments relating to actions from the Cancer Action Plan 2023-2026, and future requirements.

Strategic level buy in to make cancer prehabilitation the default

Evidence from surveys and focus groups suggests that cancer prehabilitation continues to be viewed as an ‘add‑on’. In the focus groups, participants explicitly highlighted the need for NHS Board‑level buy in, and described how reliance on time‑limited national funding renders prehabilitation activities less sustainable, implying the need for greater government buy in. This may help to explain the limited change observed in the proportion of staff reporting prehabilitation activity in their local area between the 2022 and 2025 surveys. Focus groups discussions highlighted a perceived lack of strategic prioritisation of prehabilitation in the face of constrained resources, limiting progress towards embedding prehabilitation as an early, routine part of the cancer pathway rather than a secondary add-on.

Action 50 of the Cancer Action Plan 2023-2026 initiated work with stakeholders to test and embed successful approaches to prehabilitation, while evidencing impact. An important next step would be for NHS Boards to consider implementing opt‑out prehabilitation approaches, drawing on learning from existing case studies in Scotland and across the UK, for example, where automatic referral models have been tested. This approach could support a systems-level culture change by normalising prehabilitation as an early component of treatment.^[4]

To address what was felt to be ‘patchy’ provision of prehabilitation, some focus group participants suggested the development of a prehabilitation‑specific Quality Performance Indicator (QPI) to raise visibility and prompt strategic action. While such an approach could support wider and more consistent service coverage, a critique of performance assessment frameworks for the NHS^[27] highlights there are risks associated with metric‑driven improvement. For example, a QPI focused on the proportion of patients who have been through a prehabilitation pathway may support expanding coverage of services but could shift the emphasis away from quality of prehabilitation provision. There may also be practical challenges in reporting performance in areas where no prehabilitation service currently exists. Any consideration of a prehabilitation‑related QPI would therefore need to be undertaken collaboratively, with careful assessment of potential unintended consequences to determine whether this would an appropriate approach. Alternative mechanisms to prompt strategic ownership and teams to initiate discussions about prehabilitation could be explored. Focus group findings suggest that in some cases where compelling local outcomes data exist, these have not consistently influenced senior decision‑makers. This points to potential support in how to communicate, interpret and use evidence around prehabilitation at a strategic level.

Survey findings indicated that partnership working to deliver prehabilitation varied across areas. Focus group data reinforces this and highlights a tendency for individual clinical or service ‘champions’ to contribute to variability in referral patterns and uptake within NHS Boards. This finding is also observed in a Maggie’s Prehab Pilot evaluation^11, which noted that relationships between a senior clinician and Maggie’s centres can influence referral activity. Overall the data highlight the importance of clear strategic ownership and trusted, system‑level partnerships across the NHS and the community and voluntary sectors. Support to partners at different levels to build familiarity and trust between delivery partners and promote consistent messaging about prehabilitation across a wide range of professionals would help move beyond Action 51, where the Scottish Government worked with NES to develop tools to support the delivery of high‑quality prehabilitation, to promote their use by a wide range of health professionals, and thereby a consistent messaging and quality partnerships.

Enhancing access in service development

Survey findings indicated unequal access to prehabilitation by cancer type and treatment, as well as barriers linked to geography and digital exclusion. Focus group findings reiterate these and extend our understanding of how a wider range of equalities‑related factors may influence uptake. Participants identified health literacy, work commitments, and levels of immunocompromise as additional factors affecting access, alongside the socio‑economic, geographic, and digital barriers highlighted in the survey.

These findings are relevant to the delivery of Action 48, to ensure ‘nationwide coverage of face‑to‑face universal prehabilitation’. They also highlight the need to shift focus from not just increasing referrals but to also increasing uptake following referral. Understanding why patients do not engage, even when services are available, will be essential to achieving this ambition. A recent service evaluation of prehabilitation services in remote, rural and island communities^[28] highlighted the importance of prehabilitation feeling personally relevant to patients to promote participation. Positive first impressions, a belief in the perceived benefits, being ‘taken along’ or connected to services, and direct health professional encouagement were identified as facilitators of participation. Insights from people with lived experience of cancer, such as these, add important depth to the evidence base. Such perspectives could help identify which barriers have the greatest influence on access, how these barriers and facilitators operate in practice, and where targeted action could most effectively improve engagement.

Within the next Cancer Action Plan, steps will be needed to address access barriers to existing prehabilitation offers in order to avoid reinforcing or widening existing inequalities. One focus group participant suggested behaviour change training for staff delivering prehabilitation to better support patients initiate and sustain new behaviours from the point of diagnosis. According to the Capability, Opportunity, Motivation, Behaviour change (COM-B) model^[29], three components are necessary for behaviour change: capability, opportunity and motivation. Training in behaviour change aims to support practitioners to identify and help patients overcome barriers related to these components. E-learning on Behaviour Change for Health, developed by NES, is currently available for health and social care practitioners on TURAS^[30]. Parellel action to address opportunity factors (such as service availability) and capability factors (such as transport, digital access, and patient’s time) is important so as not to disproportionately benefit some groups more than others, potentially increasing inequity. Behaviour change training should therefore be seen as one component of a broader, equity‑informed approach.

Wider literature highlights the importance of monitoring equity as health services shift to become more community‑based and digitally enabled. Qualitative research regarding access to General Practice^[31] emphasises the importance of ongoing co‑design and the tracking of equity in outcomes and experiences to ensure that service redesign does not introduce new access burdens. Similarly, an evaluation of the Prehab4Cancer initiative in Manchester^[17] recommends the use of equality impact assessments and improved recording of patient demographics to better understand who is not currently represented in prehabilitation services, and why. While not a protected characteristic, distance from services was repeatedly raised in focus groups as an equity issue. Geographical isolation, travel costs and limited transport were identified as barriers to participating in prehabilitation in remote, rural and island communities in Scotland^[28]. Mechanisms for better monitoring access to cancer prehabilitation within remote, rural and island communities would be beneficial.

Actions within a forthcoming Healthcare Inequalities Plan, referenced in the Population Health Framework^[14], will be highly relevant to the next Cancer Action Plan. In particular, work to develop practical guidance on equitable care, reduce digital exclusion, and address missingness in service data could support a more systemic approach to equity in prehabilitation. The expansion of Single Point of Contact support in Scotland^[32] provides a potential route to improve access to prehabilitation through enabling discussions about patients non-clinical needs, providing continuity in one-to-one support, and introducing an opportunity for early screening. Nevertheless, patient-level barriers raised by staff also point to the need for specific support for individuals and groups who currently face the greatest obstacles in accessing universal prehabilitation.

Investing in capturing data to support service sustainability

Focus group findings help to explain the unclear changes observed in survey data on multi‑modal staffing and funding between 2022 and 2025. Some participants described prehabilitation as being delivered through time‑limited ‘projects’ rather than embedded ‘pathways’. This helps to account for short‑term variability in reported workforce and funding profiles, including the ending of fixed‑term contracts, as well as differences that were due to survey samples across years. An evaluation of the South East Scotland Cancer Network (SCAN) prehabilitation pilots^[33] likewise highlights disruption to services due to inconsistent funding, and calls for recurring national funding to realise the benefits of prehabilitation pilots

Participants also highlighted tensions between under‑utilisation of available services in some areas and overstretched resources in others. A recurring message was the value of screening and needs-based assessment data to understand local need for prehabilitation and to plan resources accordingly. Without this data, workforce planning was felt to be reactive or outdated, rather than aligned to population need.

Action 49 of the Cancer Action Plan sought to develop tools to support implementation and the assessment of nutritional needs in people affected by cancer. The Right Decision Service hosts online toolkits for professionals^[34] and toolkits for patients^[35], including a self-screening tool have resulted from this action. Focus group findings suggest that continued emphasis is needed in the next Cancer Action Plan on improving systems that support the routine recording of screening, assessment, and outcomes data, and the ability to share these between sectors. Such systems are critical not only for informing patient care but also for local workforce planning.

Better alignment between prehabilitation delivery and digital developments, such as the Digital Front Door, could help address the IT challenges raised by staff. Specifically, by providing a portal to record screening, assessment and outcomes data that is accessible and usable to patients and across sectors, thereby accelerating progress towards the pre‑treatment ambition. This would be a logical extension of Action 47, to develop a partnership to drive forward digital innovation.

Participants also noted that gathering data requires time and capacity, which must be factored into resource planning. Evidence from a scalability assessment of the Scottish Government’s Single Point of Contact initiative^[36] suggests that navigator roles may free up clinical time by providing administrative, logistical, informational, social, and emotional support. The SPOC navigator role may be well suited to supporting screening in prehabilitation pathways. Clarifying roles, including administration and clinical support roles, within the wider prehabilitation workforce would be beneficial within workforce planning, particularly to ensure staff skills are used appropriately for both patient experience and for a cost‑effective workforce.

Relating to the strategic buy in, participants highlighted the need for greater support to ensure outcomes data reach and resonate with senior leaders, alongside investment in systems that make outcomes recording easier and less time‑intensive for staff. These findings reinforce recommendations from the 2022 and 2025 survey analyses, and from the 2024-2025 annual progress report for the Cancer Action Plan^[37], for national guidance on outcomes measurement and the development of a core prehabilitation data set. Recent clinical and service outcome measures used in SCAN prehabilitation pilots^[33] include length of stay, secondary care contacts, six-month survival rates and weight, as well as qualitative patient stories. Standardised outcomes would enable more consistent monitoring and evaluation across services, helping to demonstrate impact at both individual and system levels. This, in turn, could strengthen the case for long‑term investment and move prehabilitation away from short‑term, project‑based delivery towards a more stable and sustainable model of care.