Surgery The benefits of prehab have been a topic


of extensive research in the peri-operative realm, bringing to the fore its positive effects in optimising pre-operative health and improving patient outcomes. There is an increasing body of evidence


that not only does prehab improve quality of life but reduces post-operative complications and readmission rates. When a treatment just makes such logical sense, why doesn’t every patient have access to it? Moderating stress response and addressing modifiable factors that impact the health of the surgical population should be incorporated into every patient’s surgical pathway. However, access to prehab is inequitable across the country. The reasons, as with everything associated, are complex. To offer a multidisciplinary, personalised, sustainable service is expensive. It’s not just the need to have a dedicated hospital workforce to provide additional service that may easily be transferrable remotely – there’s also the additional resource requirements of space, equipment and infrastructure. A face-to-face service may often, though not always, be available only on weekdays, which may leave patients unable to take time off from their work or life commitments, making them unable to access it. Face-to-face prehab may preclude people who need it most, those from poorer socio- economic backgrounds, due to the opportunity costs involved through travel, childcare costs, inability to fit a session in regular hours. A suggested solution is digital prehab. Digital prehab incorporates technology


to screen, personalise and tailor prehab programmes. Remote consultations followed by remote delivery using platforms, such as Zoom or Skype, offer multiple advantages such as flexibility of scheduling, psychological safety of working in a familiar environment and a contextual advantage for the practitioner to


Preparing in advance of an operation, and in particular by taking exercise and following nutritional guidance to help build strength and fitness, halves the chances of suffering a complication.


understand the wider social determinants of a patients’ health.


It’s cost effective and scalable. It does not


have any geographical barriers, so patients living further afield from a hospital don’t miss out, and it addresses health inequalities by decreasing the opportunity costs for patients. During the last three years, we’ve worked with


over a thousand oncology patients, referred from a number of acute hospitals. During that time, the reduction in 90-day surgical readmissions for urology patients fell 50% – and over 60% for colorectal cancer resections – as compared to published data in journals. When delivered digitally, prehab can be implemented at a cost that is significantly lower than a face-to-face service, but it is just as valid in terms of patient experience.3 savings can also be achieved,4


Additional as improved


health-related quality of life leads to earlier returns to work and less demand on social and primary care.


By delivering multimodal digital prehab services, we removed some barriers to service access, even for patients who may have been feeling unwell or did not have the means to travel to the service. The COVID-19 outbreak at the time of the study might have increased the number of participants that did not have any other alternative, due to services being paused. To incorporate digital prehab as the standard of care, we clinicians need to accept three preconditions. First and foremost, think beyond the


operating theatres, hospital boundaries and organisational pathways. We must look at the patient journey, from the phone call to the GP to the presentation at the operating table for removal of the cancer. Peri-operative prehab can be offered at any point, the earlier in the pathway the better. Perhaps from the point of decision to operate, MDT meetings? We must adopt the flexibility of mind that


interventions in the peri-operative care pathway, and cancer care pathway, are not always deliverable in the hospital. There are fantastic cardiac rehabilitation and diabetes prevention models that have been successfully delivered in the community for years. The NHS Long Term Plan also aims to offer safe digitisation of appropriate patient care


pathways and prehab may just be the ideal one to incorporate both ambitions, remote delivery and digitisation. Establishment of integrated care boards and development of population health models would definitely help it be so. Second, and in my opinion perhaps the most important point, is that the digital platform used should be accessible. Simplicity is often the best way, with apps helping track compliance and adherence along with providing trustworthy resources for people. The COVID-19 pandemic has accelerated the acceptance of digital services and most of us like our apps to be concise, intervention specific, easy to navigate and integrated into our lives. At the same time, medicine is a very nuanced and complex field, hence an ideal combination would have a human element, often in the terms of screening and programme preparation, flowed by a simple to use app that can cater to the needs of anyone from the age of 18-80+.5 Lastly, while looking to guide our patients


towards digital prehab platforms, we must acknowledge the privilege and the responsibility of the position of trust we have. We must guide them to services that have been acknowledged as offering an effective and impactful solution for the challenging problem of offering prehab. We also bear the responsibility of ensuring these solutions are cost effective to ensure we offer value-based interventions. A recent study by Cancer UK revealed


how 20,000 cancer deaths a year could be prevented by 2040 if the government took certain steps to combat the disease – including a recommendation to “implement innovative technologies more quickly and speed up waiting lists”.


While multimodal prehab can play a part,


it’s not a panacea and for it to work efficiently within the NHS it must incorporate the following principles:


Remote/digital delivery In our post-lockdown world, the vast majority of us appreciate the flexibility, accessibility, privacy and support offered by live streaming. Delivery into the home will mitigate the need to travel to a prehab unit, widening access to those who may not be able to attend the face-to-face in- hospital sessions.


February 2024 I www.clinicalservicesjournal.com 25


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