At the time of its inception, prehabilitation for surgery was a novel concept.
PREP-WELL is the UK’s first comprehensive, supervised community-based programme, specifically designed to improve the health and wellbeing of patients before surgery.
Introduced by South Tees NHS Foundation Trust, the pilot ran for 12 months, from January 2018 to January 2019. It helped patients access progressive, supervised support for several preoperative risk factors, in a one-stop setting, in the weeks before surgery.
The service was modelled on the success of the national Cardiac Rehabilitation platform, whilst aligning with NHS priorities of promoting healthier lifestyles through supported self-management closer to home.
The project was unique as it was delivered by a regional health sector partnership across Secondary Care, Primary Care, Public Health, the Voluntary Sector and Academia. This pioneering cross-sector approach is an exemplar model of integrated care.
Surgery places significant physiological stress on the body with ‘less fit’ patients at highest risk. Several common modifiable risk factors such as anaemia, smoking, anxiety and low physical fitness have an adverse effect on outcomes after major surgery, including postoperative complication rates and recovery.
Prehabilitation services help patients improve their ‘fitness for surgery’ but are not widely available, highlighting a need for improvement.
A scoping period by the project team at the James Cook University Hospital found that current preoperative pathways were fragmented and encouraged silo working. Decisions on ‘fitness for surgery’ occurred late, allowing minimal time to improve health. There were long periods of earlier underutilised time. Also, health and wellbeing services were fragmented and difficult for preoperative patients to access. The basis of the PREP-WELL pilot came off the back of a two-year programme of work undertaken in 2015-16.
To understand the problem in the area, the team wanted to know the health behaviours of people having surgery. An initial audit of 450 surgical patients at the James Cook University Hospital found that one-third of patients were engaged in at least one risk behaviour.
To determine the scale of this problem, as well as exploring patients’ willingness to engage with a lifestyle change, the team also developed a multi-centre patient questionnaire. It assessed the prevalence of behavioural risk factors (e.g. physical inactivity, smoking, hazardous alcohol consumption) and attitudes to preoperative behaviour change in 299 patients awaiting surgery.
More than three-quarters of patients (87.3%) had at least one risk behaviour, with 42.1% having two or more. Importantly, results also demonstrated high levels of patient motivation to change behaviour; however, confidence levels to achieve this were significantly lower. This work was instrumental in developing a co-ordinated multi-modal intervention addressing behaviour change.
PREP-WELL was designed to create a very different experience for patients; tackling personal, social and structural barriers to engagement and behaviour change.
The programme benefitted from being run in a community health facility, The Live Well centre. This is a “one-stop” centre containing a range of public health and lifestyle interventions, including smoking cessation, specialist alcohol services and a gym, meaning patients can access all support services in one setting. The centre also offers easy access due to its location in central Middlesbrough, good parking facilities and excellent public transport links.
The exercise training sessions and introductory seminar (information session for patients and their relatives) were delivered in group sessions. The peer support networks developed during the group exercise sessions bolstered patient ‘buy-in’. These sessions also provided opportunities to discuss any concerns or questions with health professionals. Patients were able to understand that they were not alone in their journey through surgery, with many developing new friendships within the groups. A few consistent themes emerged from the patient stories. This included the peer support provided for one another through the group/class environment and that participation provided them with incentive or motivation to keep going when they might otherwise be having a ‘bad day’ and have lost interest. Another key theme was the positive impact participation had on mental and physical health.
The project’s overarching achievement was to embed the service into routine clinical care across a range of surgical specialities. The vast majority of patients (>70%) gained clinically meaningful improvements in their health status and quality of life (before surgery) following participation. Several patients initially deemed too ‘high-risk’, were able to have surgery by improving their fitness and wellbeing following participation. Patient feedback about the programme and the team was excellent.
The reason PREP-WELL was such a success was due to stakeholder support and investment (with matched project funding); patient engagement and support for one another through effective team working and a central easily accessible one-stop location.
The pilot will enable the team to develop the service to benefit a broader spectrum of patients. Over the next four years, the team will work together to increase capacity and support more local people to improve their health and wellbeing before surgery. This will focus on people
undergoing surgery with vascular disease and treatment for cancer; hip and knee replacements; and a remotely-supervised digital offer. Patient feedback was instrumental in the decision to develop the digital platform to reduce the burden on their time to attend assessments. Sport England will support this (through the South Tees Local Delivery Pilot: You’ve Got This) and Macmillan Cancer Support.
PREP-WELL has considerable potential to improve health outcomes and care for a higher number of people, and the aim is to roll it out region-wide.
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