Trust launches a research trial to deliver personalised care plans to cancer patients, resulting in reduction in post operative length of stay, saving £252k in costs

Synopsis

WesFit is an innovative research trial, which delivers Personalised Prehabiiitation Care Plans (PPCP) to people, recently diagnosed with cancer. This quote demonstrates our direct impact: “I was at a very low point, having been ill for 18-months. Major surgery was proposed and I was offered the WesFit trial, where I received counselling and fitness sessions. My physical abilities and emotional outlook were transformed prior to surgery. The programme significantly prepared me for surgery, meaning I was discharged day 4 and made a full recovery. I also continue to be far more aware of my health than previously.” (Keith Cockerton, patient).

Ambition

The rationale for WesFit came directly from our patients. When we spoke to them about their life with cancer and their cancer care they consistently described an overwhelming sense of having “Become a Cancer” on receiving a diagnosis.

Our cancer alliance, bringing together patients, system leaders and innovators, was uniquely placed to tackle this loss of identity and its impact on people’s ability to cope. University Hospital Southampton NHS Foundation Trust had already demonstrated powerful effects of exercise for cancer surgery patients on recovery, quality of life and feeling of empowerment. Patients experienced a change in their outlook from enduring cancer and being defined by the changes wrought by it and its treatment, to that of an empowered contender, getting into the best possible shape to meet their challenge.

We saw the opportunity to work across Wessex to accelerate our research and at the same time rapidly change frontline practice whilst building a robust evidence base through a randomised control trial.

Our aim was to engage with patients from the point of diagnosis and support them in their community, to establish the impact of giving them physical and/or emotional support from the earliest possible time. Our challenge was to create an innovative, scalable delivery network via community-based gyms and cancer support centres, mobilise a new workforce (including trained Physical Trainers) and put in place new referral and care management processes. This was done within the context of a Randomised Control Trial (RCT) enabling effective evaluation of the financial and efficiency impacts of these innovations, and of the effect on participants’ consequent surgical recovery and longer-term outcomes. This was of critical importance in order to provide evidence for the adoption and spread of this approach beyond Wessex.

The UHS Fit-4-Surgery group was the first to show the harmful effects of chemotherapy on physical fitness before surgery and the consequent effects on perioperative outcome across diverse tumour types. They went on to demonstrate the beneficial impact of exercise interventions in reversing the effects of chemotherapy on physical fitness at whole-patient and cellular levels, as well as providing the first evidence in humans that exercise augments tumour regression.

Outcome

We had a really big challenge to scale the programme and advance our ambition to build capacity, delivery models and processes needed to integrate prehabilitation programmes into cancer pathways across the region. We needed to explore innovative ways of providing exercise, nutritional, and psychological support in the most effective and efficient way possible. Key to the success of this programme has been a supportive local leisure industry and Wessex Cancer Trust, a voluntary organisation providing emotional, psychological and practical support to people affected by cancer in Wessex.

Further financial and efficiency savings arise from our partnerships with local voluntary and leisure centres. Beyond the patient benefit of bringing prehabilitation to them, this reduces costs and lays the basis for a sustainable model scalable nationally, in conjunction with this, we have also been liaising with both local and national commissioners to assess the sustainability of our model for translation into clinical practice and tariffs as well as national community providers (e.g. UKActive) to enable widespread effective community implementation.

WesFit is the first fully powered Randomised Controlled Trial that will provide NHS England with definitive evidence of clinical-and-cost-effectiveness of physical and psychological cancer prehabilitation.

Qualitative exploration of patients’ experiences of earlier exercise prehabilitation trials revealed they wanted help to continue to exercise after surgery. Using evidence from behavioural science the WesFit trial has integrated a process to support long-term behaviour change. Supporting long-term engagement in exercise may also lead to secondary cancer prevention and reduced chronic disease burden.

“But it also – made my mind up that I was going to go riding again. Get my own bike out and go riding and— and now. I’ve got — a fitness trainer. I bought a fitness trainer. So, yeah, it’s— made me more aware that I need to maintain those fitness levels” (patient)

WesFit has been delivered at scale, across Wessex, which includes Dorset and Hampshire, building the evidence base for an efficient and effective service. We have demonstrated that this can be achieved prior to implementation of Integrated Care Systems. These factors are critical to building a sustainable model for delivery and longer-term behaviour change and secondary prevention amongst patients that will reduce future health needs, and demonstrate a way forward for meeting increasing NHS pressures. In conjunction with this, we have also been liaising with both local and national commissioners to assess the sustainability of our model for translation into widespread clinical practice.

Spread

This initiative built on our previous and on-going relationship with multidisciplinary teams. WesFit initially opened only to patients with colorectal (colon and bowel) cancer, however, within the first few months, due to enthusiastic buy-in from the clinical teams and lead cancer nurses, we were able to rapidly expand and roll-out to patients’ oesophagogastric (stomach and gullet), hepatobiliary (liver and pancreas), thoracic (lung), urological (bladder, kidney and prostate) and maxillofacial (head and neck) cancers within the first year.

WesFit Trial delivery is supported by the National Institute for Health Research Clinical Research Network (CRN) and WesFit is a championed trial on the CRN research portfolio. This results in matched funding and support from our local CRN to deliver this important trial.

We are very proud to say that we have significant traction and spread of this initiative. We have been contacted by 27 NHS hospital sites across the UK -15 out of 19 Cancer Alliances have contacted our team to discussing involvement in WesFit and we have had international buy-in and interest. This has been welcomed by NHSE as recognition that our team will provide the evidence that will be translated into clinical practice.

Our team consists of world-leading clinicians and academics, partnering with patients, local NHS and University key executive stakeholders, charities, community hubs, community exercise providers (e.g. UKActive) and social care. We have been invited to present our prehabilitation data at numerous national and international meetings, often as keynote speakers. We have published more than 30 peer-reviewed papers in the field of prehabilitation. We have completed 8 prehabilitation clinical trials.

WesFit and our previous clinical trials were instrumental in creating and formalising ’The International Prehabilitation Society”. We also hosted the 3rd World Prehabilitation Conference in London earlier this year, attended by over 500 delegates

WesFit will deliver on key points of the report’s action plan and provides the blueprint on how to integrate prehabilitation into established clinical pathways.

We will be conducting health economic assessment in partnership with Macmillan. This will form a key part of our final evaluation to assess cost-benefits as well as sustainability. In parallel to the delivery of this trial, we are collaborating with the Academic Research Centres, Academic Health Science Centres and the Director for Implementation Science at our local Academic Health Science Network to form national Beacon sites to initiate early implementation.

Value

The cost-effectiveness analysis from our clinical trials has demonstrated that prehabilitation prior to cancer treatments and surgery results in significant cost savings. There was an overall saving in 60 patients of 252K in reduced postoperative length of stay and £2,700 saving in reduced 30-day readmission rates. This is in addition to the improvements in patient’s experience of cancer, improved long-term patient health and resilience. The total cost of these prehabilitation interventions is approximately £120 per patient. We co-designed our multi-modal clinical trial, WesFit, with people affected by cancer. These participants are now integral members of our team.

We have partnered with charities and community exercise facilities to ensure that the support we offer to patients is both local and accessible. Our established partnerships mean that following trial completion, we have a sustainable infrastructure that will enable rapid translation into clinical practice.

This trial is being delivered in Hampshire, Dorset and Isle of Wight, therefore, in remote rural, inner-city and Small Island locations across Wessex. This strategic framework, which is integral to our trial, will facilitate implementation, adoption and spread across multiple health and care systems. We have, therefore, demonstrated a reduction in variation as we deliver the same robust quality and quantity of care near the to the patient’s home.

We have developed a unique model, which provides the infrastructure to enable rapid translation of our research findings into clinical services for people with cancer. The Wessex Cancer Alliance includes prehabilitation as a fundamental component of Personalised Care Programmes to maximise the health and well-being of all patients from the point of diagnosis. WesFit will inform an exemplar model of personalised prehabilitation care plans which will be used to determine national and international health system implementation.

The Golden Thread link between vision, analysis, systems and patients, has led to a shared understanding of how the vision, goals and values of WesFit relate, this has allowed the team members to make conscious contributions and take ownership for which they are responsible. We have performed numerous patient focus groups our board and steering group includes patient, third sectors and all other key stakeholders as representatives. We believe, both from the research outcomes and our patient stories, that this ground-breaking and acclaimed research addresses critical gaps in cancer care.

Involvement

Patients have always been at the centre of design and delivery of our research trials spanning over 12 years. We have collaborated various organisations (e.g. The Involve organisation) and clinical speciality groups and most importantly with patients on the submission of grants and have included patients as co-applicants. We feel that patient involvement and collaboration in all of our work has been the key to our success.

WesFit has been highlighted as a key exemplar model for Biomedical Research Centre reports and reviews. One of the main aims of our initiative is to promote and support long-term behaviour change and self-care. We have worked hard with patients to ensure that the interventions are appropriate and in a safe environment.

The team are now in discussions with the Director of the Centre for Implementation Science regarding completion of the RCT in a timely fashion and early implementation of services at beacon sites.

We feel that as stated above we are proud to say we have developed extremely strong partnerships with numerous stakeholders across Wessex and wider-reaching to improve patient care nationally and internationally. We would only have been able to deliver this in a cost-effective and effective sustainable clinical model which we hope that these PPCPs are adopted and spread to benefit patients worldwide

WesFit is part of a wider programme designed to rapidly translate our trial findings into standard clinical practice. Aiming to establish evidence for NICE and NHSE Commissioners, WesFit builds on over 12 years of research and new, nationally and internationally adopted best practice that is in many cases informed by that research

This approach is an integral part of the Wessex Cancer Alliance strategy, the aim of which is to improve both quality and quantity of care. We are, therefore, creating a partnership and shared decision making with patients and health professionals, helping and supporting people to take more control, of their health

WesFit is delivering personalised prehabilitation care plans (PPCPs) across Wessex using an innovative, new and effective approach, with community delivery partners and equality of access of care for all patients.

Some quantified examples of the benefits are included in the section below, and more sites have come on board throughout the last two years, for example, Plymouth. As more data is captured this will be used to evidence the benefits of a full national rollout of the programme.