Surgery
The service must be highly personal We are all a sum of our physical, psychological, social and familial experiences. Add to that the unique nature of clinical disease and treatment planned, it’s no surprise that evidence6 demonstrates that personalised interventions, such as tailored prehab programmes, have far greater impact than generic advice and information. An individualised plan, within the framework of multimodal guidance, is needed.
Clinically-led and supported To achieve meaningful and long-lasting results, you must offer an inter-professional programme allowing for multiple healthcare professionals to coordinate care to facilitate optimal use of the pre-operative time and to embed behavioural change before surgery.
It must offer value for money In order to be sustainable beyond its ‘pilot stage’ and to impact the greatest number of patients, any programme – and the interventions offered – must be cost effective. While we look at incorporation of prehab, we would be able to succeed in our efforts more if we are aware of the pitfalls that often are often encountered on the way to establishing sustainable services in the NHS. While there may be many challenges, in my experience they often fall into two broad categories: the distance between policy and coal face implementation, and the distance between commissioners and service providers. The Department of Health and Social Care/
NHS regularly announce policies, but often fail to announce financial foundations for the policies. Small enterprises frame projects in accordance with the national policy decisions and may regularly receive a surprise when they present their models to the people with purchasing power, as they have no funds to allocate to the policies. Uncertainties around long-term funding makes it hard for the small healthcare enterprises to attract and retain talent/staff that do require a level of assurance around their income.
‘Homegrown’ vs off the shelf solutions The “Not Invented Here” syndrome that many large organisations suffer from – when employees or teams resist external solutions in favour of developing their own, leading to inefficiencies, slower innovation, missed opportunities, and a closed culture – is also prevalent within hospitals, both NHS and private. To address this problem, we need to promote a collaborative culture, emphasising results
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over the source of solutions, recognise external expertise, evaluate costs and benefits, and have leadership support for open-mindedness. There is often confusion around separation of the means from the end. In these trying times, prehab presents a solution for some of the many challenges the NHS faces. Properly administered, its impact extends beyond reduction in complications and readmissions and presents a real opportunity to positively impact the health of our population and our nation.
References 1.
https://www.rcoa.ac.uk/patients/patient- information-resources/preparing-surgery- fitter-better-sooner
2.
https://cpoc.org.uk/sites/cpoc/files/ documents/2023-09/CPOC_Reduce- WaitingListsv2.pdf
3. Seery T, Wu F, Hendricks E, McDonald J, Laza-Cagigas R, Elliott S, Rampal T. Patients’ experiences of virtual prehabilitation during the COVID-19 pandemic. Patient Educ Couns. 2022 Feb;105(2):488-489. doi: 10.1016/j. pec.2021.07.052. Epub 2021 Jul 31. PMID: 34376302; PMCID: PMC8325374.
4. Gkaintatzi E, Nikolaou CK, Rampal T, Laza- Cagigas R, Zand N, McCrone P. Cost Analysis of a Digital Multimodal Cancer Prehabilitation. Curr Oncol. 2022 Nov 29;29(12):9305-9313. doi: 10.3390/curroncol29120729. PMID: 36547143; PMCID: PMC9777147.
5. Wu F, Laza-Cagigas R, Rampal T. Understanding Patients’ Experiences and Perspectives of Tele-Prehabilitation: A Qualitative Study to Inform Service Design and Delivery. Clin Pract. 2022 Aug 16;12(4):640-652. doi: 10.3390/
clinpract12040067. PMID: 36005070; PMCID: PMC9406597.
6. Waterland JL, McCourt O, Edbrooke L, Granger CL, Ismail H, Riedel B, Denehy L. Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis. Front Surg. 2021 Mar 19;8:628848. doi: 10.3389/fsurg.2021.628848. PMID: 33816546; PMCID: PMC8017317.
CSJ
About the author
Professor Rampal is a Consultant Anaesthetist with a keen interest in Peri-Operative care and Population Health. She trained at the Barts and the London School of Anaesthesia where she was awarded the Excellence Award for Academic Achievement in 2008. She is the Founder of QuestPrehab, which aims to improve healthcare outcomes and health related quality of life for patients in need of major medical intervention.
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