Case Studies: Psychological Support and Social Prescribing

Empowering Patients and Carers Before Surgery

Nottingham University Hospitals NHS Trust (NUH) established its Prehabilitation Service in April 2022 for major cancer surgery. The service aims to improve post-operative outcomes such as mortality and length of stay by optimising patients’ physical fitness, and mental and emotional wellbeing ahead of surgery. Exercise interventions have been widely discussed; here we focus on the psychological aspects of Prehabilitation, specifically NUH’s social prescribing and psychotherapy service.

Psychological support is one of the pillars of our prehabilitation programme: it is well known that anxiety and fear are common in cancer patients, associated with the diagnosis and the anticipation of surgery. By providing our patients with an enhanced psychological care package within their prehabilitation, we aim to achieve compliance with physical activity, as well as direct improvements in mental health that last long after the surgery is complete.

Prehabilitation and optimal psychological support can be viewed as the ‘tap’ in Crawford’s stress bottle model – releasing stresses so the bottle doesn’t overflow and allowing focus on preparation for cancer treatment. [see picture below]

Like other trusts in the country, NUH faced a backlog of operations following the Covid-19 pandemic. By creating an effective and sustainable prehabilitation service, we can contribute to the increased throughput by reducing number of bed days with a specific focus on higher levels of care. NUH serves a population of over 6 million, and Nottingham City residents experience high levels social deprivation: a large population target for intervention and improvements.

We offer prehabilitation to patients to cancer patients undergoing major surgical intervention. Macmillan estimates that over 70% of people living with cancer need emotional support, with two in five affected by depression, and four in five experiencing a financial impact. We learnt quickly that psychological and social support were key aspects of getting patients to attend exercise sessions or adhere to independent exercise programmes.

Alongside physical exercise, nutritional support and encouragement to make behavioural changes, NUH’s prehabilitation programme includes comprehensive psychological support. During prehabilitation consultation patients are screened for their emotional wellbeing using EQ-5D-5L, PHQ-9 Depression, and GAD-7 Anxiety questionnaires.

Our service includes one full time equivalent social prescriber link worker from Self Help UK. Social prescribing is a referral to a link worker, who can actively support the patient with their non-clinical needs, considering social, financial and environmental factors. The link workers can offer community-specific knowledge and address non-medical issues that may be a source of burden for the patient, where healthcare professionals cannot. Most social prescribing referrals come from Primary Care, and so we believe NUH is unique in utilising social prescribing this way.

All our Prehabilitation exercise professionals are trained to deliver cancer level 2 psychology support (additional training in assessing and supporting patients with psychosocial needs) from the East Midlands Cancer Alliance centre for psychosocial health. Patients who are identified as requiring additional support as moderately severe or higher (>10 on their PHQ-9 or GAD-7) on their emotional wellbeing questionnaires are referred to up to six sessions of video psychotherapy delivered by The East Midlands Cancer Alliance centre for psychosocial health.

The service has received an average of 57 referrals per month in the last year, with eight patients per month on average accessing social prescribing, and two patients per month on average accessing the clinical video psychotherapy service.

Evidence suggests that a multimodal approach to prehabilitation is more effective than unimodal (i.e. without psychological support) at improving post-operative outcomes. Provision of each modality should work synergistically, such that successful psychological support can enhance physical activity and compliance with the whole prehabilitation programme. Evidence demonstrates social prescribing in Primary Care can: reduce levels of depression, anxiety and loneliness, improve social connectiveness and quality of life, and reduce NHS consultations via GP, ED, or outpatient appointments. It stands to reason that some of these benefits could also apply to our cancer patients in secondary care.

The Prehabilitation Service has analysed pre-programme and post-programme psychological measures, and patients have had favourable psychological outcomes across the board. On average:

• EQ-5D-5L wellbeing score improved by 7.7
• PHQ-9 Depression score decreased by 2.3
• GAD-7 Anxiety score decreased by 2.2
• Alcohol intake (units) decreased by 2.1 units.

There have also been demonstrable improvements in physical fitness and strength. On average:

• Grip strength increased by 1.3kg (left) and 1.7kg (right)
• No. of sit to stands in 60 seconds increased by 6.1
• Incremental Shuttle Walk test increased by 54.6 metres
• No. of minutes of physical activity per week increased by 138 minutes

• No. of strength sessions per week increased by 2.3.

There has been a decrease in mean length of stay of 1.7 days for prehabilitated patients, totalling 691.5 actual bed days (67.8 level 2 bed days) to date and significant financial savings with their associated costs. Emergency department attendances are reduced by 3.5%, and readmissions within 90 days by 17.7%.

Qualitative feedback from patients has been overwhelmingly positive, in that they feel physically and mentally more prepared for the demands of cancer treatment. Specifically to social prescribing, patients report being able to discuss concerns that don’t feel medically relevant with their link worker. This has enabled them to offload worries, in turn improving confidence and ability to participate in the wider prehabilitation programme. 83% of patients who accessed the social prescriber link worker saw an improvement in their Health Needs Assessment (HNA) scores.

Patient partners were involved from the start in planning the Prehabilitation Service, sitting on staff interview panels, contributing to procurement processes and helping with the overall development of the service. Feedback is sought from every patient participating in the programme and changes are made based on this – e.g. the development of an integrated care record, the Prehab to Rehab pathway.Patient partners were involved from the start in planning the Prehabilitation Service, sitting on staff interview panels, contributing to procurement processes and helping with the overall development of the service. Feedback is sought from every patient participating in the programme and changes are made based on this – e.g. the development of an integrated care record, the Prehab to Rehab pathway.

Representatives from the Prehabilitation Service sit on the Nottinghamshire ICB, to share learning and encourage discussion. There is a monthly governance meeting where updates and case studies are discussed, and feedback considered for improving the service. A recent achievement has been success at the Patient Experience Network National Awards (PENNA) 2023, where by highlighting our learning and developments, we won in two categories for partnership working and personalisation of care.