Cancer Prehabilitation: Staff perspectives on implementation

Conclusion

The aim of the focus groups with cancer prehabilitation staff was to explore what is helping and what is hindering the implementation of prehabilitation in Scotland from a staff perspective. Focus groups were recommended following an analysis of a national survey of prehabilitation staff undertaken in 2025. The survey findings indicated a need to explore staff views in more depth around multi-modal staffing and screening practices, the integration of prehabilitation and rehabilitation services, funding models and learning about how to sustain activities as pilot projects come to an end. These were explored through two overarching topic guides: ‘partnerships and pathways’ and ‘service renewal, re-design and sustainability’.

Staff focus groups helped to provide greater context to the survey findings, deepen an understanding of how prehabilitation works in practice, identify barriers and enablers to effective delivery, and inform areas where further action is required in the next Cancer Action Plan.

Seven focus groups were held online with 32 prehabilitation staff representing different sectors and roles. Six main themes emerged from the discussions:

1. The role, framing and messaging around prehabilitation

2. Strategic commitment and coordination at senior leadership levels

3. Referrals onto, and touchpoints along, the pathway

4. Collaboration – awareness, trust and working across organisations

5. Reducing barriers and promoting equity of access

6. Planning and resourcing in services

Across focus groups, a recurring theme involved prehabilitation being seen as an ‘add on’, and that simplicity in messaging could help staff and the wider public understand prehabilitation and its benefits. This includes at strategic NHS Board level, where support gathering and communicating robust evidence surrounding its effectiveness and cost effectiveness could improve buy in of senior leaders and allocation of resource with which to deliver prehabilitation. This could be supported by systems-level changes, such as a minimum data set for prehabilitation and close alignment with digital advances to make the recording and sharing of patient outcomes easier.

Equity of access was a key and recurring concern for staff. They emphasised the need for prehabilitation services to recognise and address barriers facing patients and staff, and at system level, and to design pathways that acknowledge that patient engagement at initial cancer diagnosis may be low. Hybrid, flexible models of delivery and local delivery, and multiple touch points on the pathway, were seen as important for reducing patient barriers to access. At service level, specific support to improve access and uptake among groups who experience barriers to universal prehabilitation is recommended.

Workforce capacity, especially specialist allied health professional resource, was highlighted as a constraint to implementation. Participants suggested navigator and health care support worker roles may reduce referral workload for CNS and promote equity of access for patients through greater consistency in signposting to universal services. The clinical skills required for this role in rolling out screening should be explored and clarified. The importance of screening data was emphasised so that resourcing can be driven by need rather than by determining what support is available.

Participants gave examples of effective cross-sector collaboration to deliver prehabilitation, as well as highlighting that this is ‘patchy’, as indicated from survey results. Trust in governance and training, and data-sharing were highlighted as important enablers of effective integration of the community and voluntary sector and NHS. Support across all levels, is recommended here for the next Cancer Action Plan to actively build trust and familiarity between delivery partners.

For next steps, there was a call for prehabilitation to be viewed as a core element of treatment and not an ‘add-on’. This could be facilitated by NHS Boards reviewing prehabilitation pathways to ensure these are early and opt-out. Consistent messaging about prehabilitation from a range of professionals was repeatedly highlighted as important. For this reason prompts for professionals from different clinical backgrounds to consider prehabilitation and foster a whole team approach to prehabilitation is recommended. ‘Quick wins’, defined as low effort, high impact activities identified in analysis, provide practical examples of such prompts.

There are limitations of this focus group analysis, including that the sample was primarily drawn from staff who had already participated in an online survey, and who may hold stronger views about prehabilitation than is representative of the wider cancer workforce. In addition, group dynamics may have contributed to a higher level of consensus drawn from conversations than may exist in reality.

The focus group findings could be complemented by discussions with people with lived experience of a cancer diagnosis to better understand access to prehabilitation, and the factors influencing engagement with (or non‑engagement in) universal prehabilitation offers. In addition, testing the recommendations with senior leaders, managers and planners in NHS Boards and Health and Social Care Partnerships would help clarify where they are already being implemented and provide practical case studies that may be transferable to other services within the Health and Social Care Service Renewal Framework.