Transcript Disclaimer – Please note that the following transcript has been machine generated by an AI software and therefore may include errors or omissions.

Robin Daly
Hello and welcome to the Yes to Life show on UK Health Radio. I’m Robin Daly, host for the show and founder of Yes to Life, the UK charity working to improve cancer care in the UK by integrating conventional cancer treatments with a wide raft of lifestyle and complementary approaches that are fast-gathering evidence for their ability to improve quality of life and outcomes. Today I’m looking into a topic that didn’t even exist a few years ago, prehabilitation. It’s now quite a buzzword in certain circles and Prof Tara Rampal is a notable activist in pushing forward the agenda for prehabilitation in the UK and speaking to Prof Rampal about the benefits of prehab and also about the prehab service she’s developed. Prof Rampal, great to have you as my guest on the Yes to Life show.

Prof Tara Rampal
Thank you very much for the invitation.

Robin Daly
Well, thank you for being so willing to come and speak about the importance of prehabilitation for people diagnosed with cancer. The reason I contacted you was because I saw an eye-catching headline in the national press saying patients offered yoga, tai chi and boxing prehab classes in an effort to slash cancer readmission rates by half. And it had the subtitle readmission to hospital following cancer surgery cost the NHS 1.7 billion a year. So this article is actually all about work you’ve been doing in the realm of what is now referred to as prehabilitation. Can we start out from the beginning by establishing exactly what prehabilitation is?

Prof Tara Rampal
so prehabilitation. It’s not a new concept. It is a concept which has arisen in its discrete form from a lot of epidemiological evidence which came from the field of perioperative medicine. If you look at it, we know fitter patients have better clinical outcomes and which evolve to cancer continuum, a point on the cancer continuum anywhere in between the diagnosis to the start of active treatment where we can identify the impairments that people may have and then design targeted interventions to help prevent the risk of any future complications and increase their physiological and functional reserve. So essentially, you know, your physical activity, your nutrition, the psychological support and lifestyle modifications and these are the four tenets, the four fundamental pillars on which prehabilitation is built on. In common parlance, we are very used to rehab, you know, you have an injury and then you want back to work and then, you know, that’s where you have your physiotherapy appointment, your occupational therapy appointment, you may meet with some dietetics colleagues to see how to build up after an injury after a major operation. So prehabilitation takes that concept and moves it more the strain. So it starts building in a reserve. It’s like training to going up a mountain, climbing a summit. You don’t want to start the climb on an empty pack and that’s what prehab is and it helps people build up the physiological reserve so that not only do they tolerate the onslaught of treatment, as you and I both know, the cancer treatment itself can be very devastating for the body, for the psychology. But if there are any complications, they have enough fuel in the tank to deal with the complications and go back to the quality of life and this is the crucial point and I think we’ll come back to this later in the discussion, healthcare related quality of life which they enjoyed because that’s the whole point of the interventions we offer.

Robin Daly
Absolutely right. Great, also as marvellous and completely makes sense. So I think it’s amazing that this stuff actually gets talked about seriously these days. I mean what we’re discussing are what would come under the umbrella of lifestyle interventions. So we’re talking about, as you said, things like exercise and diet. And the context here is of preventing recurrences of cancer, something which all of the might of conventional medicine actually struggles with. Do you have some facts and figures at your fingertips regarding the number of successful treatments that actually then turn around and turn into a recurrence and a poor prognosis shortly afterwards?

Prof Tara Rampal
So the benefits of prehab, they have been a topic of extensive research in the medical world, which are bringing to full the positive effect in optimizing health and improving patient outcomes. Now, the majority of the research has looked at traditionally the complications which arise as a result of treatments, and prehabilitation has been very successful in preventing the complications, both surgery and the non-surgical, for example, chemotherapy-induced complications such as fatigue, and we know exercise is an important part of that, which in turn improves the compliance with the treatment that people have been having, the traditional treatment as well. We also know that prehab reduces length of stay in hospitals after an operational and readmission rates. There have been, you know, why? Now, the reason you asked about cancer recurrence, and I’m not an oncologist, so I’m not somebody who can put a figure to that, but there are encouraging results which are coming in from studies, and some of them are, you know, looking at tumor recurrence, tumor growth, and the positive impact of exercise onto that, and why is there benefit of prehabilitation? So benefit might be for many reasons, but we think it’s as a result of metabolic flexibility, as a result of decreasing the stress placed on the body, both physiological stress, and it’s as a result of increasing, you know, addressing the antioxidant capacity, insulin resistance, and all these issues which arise as a result of the stress that the body undergoes. So moderating stress response and addressing the modifiable factors, and these are the reasons which impact the health of our population, and that’s what we recommend prehabitation should be incorporated in every patient’s pathway.

Robin Daly
But it is massive because if you prevent a recurrence, that is a major, major intervention, isn’t it? Because of course, you know, if you treating cancer for the first time at maybe an early stage is one kind of deal. But treating a later stage cancer with secondaries and a recurrence is a completely different order of things, isn’t it, for the patient. so if you couldn’t have an intervention which actually changes the chance of that happening, that’s a seriously important intervention for a patient.

Prof Tara Rampal
Well, what we discussed is, for example, so this is many four approaches of rehabilitation. When we look at exercise, nutrition, and then modified lifestyle factors such as smoking cessation, alcohol moderation, they in themselves, we know the single most important thing you can do for your health is stop smoking, for example, followed by starting to start exercising. So all of these help prevent, you know, these are the reasons we know smoking, physical inactivity, all these reasons that can be associated with cancer can be addressed. Then we also know the complications such as readmission, which may happen after cancer resection surgery can be decreased as well. But with regards to, if I cannot today say that there is enough robust evidence present that definitely doing just exercise will prevent recurrence of cancer, but there is a lot of robust trials, clinical trials that are going on, and we are really hoping that in a few years, they’ll be able to tell us exactly how the mediation happens and exactly if and how the exercise, nutrition, and diet have a very positive impact on cancer recurrence itself, our only focus is because on the readmission rates after cancer, which is, you know, it’s not the relapse of cancer, it’s readmission.

Robin Daly
Yes, okay. Yeah, that’s different. But yeah, it’s a huge cost. And of course, it majorly affects the quality of life for the patients. They can stay well.

Prof Tara Rampal
Yeah, I think in our field sometimes, we forget the focus on health-related quality of life. We forget the focus on patient reported outcome measures, because despite a lot of research and like you say, the complementary aspect of medicine, majority of our traditional markers focus on length of stay, on complication rates, on readmissions. But we forget why people come in to have the treatment in the first place. What do they want at the end of this treatment? We forget, like, you know, for people who have lives, they have complex psychosocial needs. So if you have a treatment that precludes you because of the disease itself or because of the nature of treatment, that may lead later on to, you know, regret and it may lead on to other problems which we try to address. We try to address the health care-related quality of life. And time and again, there have been studies, observational trials as well, which have proven that prehabilitation helps people with health-related quality of life. And which I think we have started to recognize. We started to recognize within our whole framework and commissioning of services, National Institute of Clinical Excellence. We started to recognize that it’s quality-adjusted life years. It’s not just the life years we offer people, but quality in those life years that we should be also looking at all the interventions we started offering.

Robin Daly
I’m very pleased it’s happening. I mean, I think, you know, back in the past, it was kind of like, you’re lucky to be alive, don’t winch was kind of the attitude, but it has moved on from there. People are beginning to think about this, and they are realizing that saving somebody’s life and giving them a life they don’t really like is not a great result, actually. So, yeah, very good that you’re taking all of that into account. Okay, so it seems like one of the areas we’re talking about here is what is, it’s a little intangible, but it’s talked about a lot these days, which is well-being. The penny seems to be finally dropping that well-being is actually a real thing, you know, it’s not just something made up by a bunch of hippies in the West Country or the marketing department of a supplement company. It does actually matter what your background level of health is when you are faced with a difficulty, you know, Covid demonstrated that the people who had difficulties were in real trouble when Covid came along. So, do you want to talk a little bit about well-being and its place in things, how we’re looking at it now?

Prof Tara Rampal
Yeah, I think if you look at well-being, it is a component in general of not just the emotional well-being, it is the social well-being, it is the physical well-being. And sometimes, for us clinicians, it is also to look at the decline in well-being, being defined as decline in functional capacity. And functional capacity is not just the physical capacity to pick up your child in your arms and stand up. It’s having the engagement, it’s having the motivation to be able to engage in those activities. We know that people with cancer have an accelerated decline in their functional capacity. And there are lots of reasons this tends to happen. These can be patient characteristics, you know, what biological sex they are, how old they are, what their financial status is, what educational attainment could be. These could be clinical factors, which are your poor baseline functional capacity, poor treatment, pretreatment fatigue, pretreatment shortness of breath or dyspnea, poor nutritional, polypharmacy, complex comorbidities, cognitive impairments, obesity, depression. There are treatment-related factors such as chemotherapy, radiotherapy, complications, and then there are cancer-related factors. And these are factors like the kind of cancer, the stage of the cancer. And what we’re trying to do here is that there are things we cannot do anything about, you know, the cons that you have been dealt with. We cannot look at the age that we have at which we receive the cancer diagnosis, the type of cancer diagnosis, the stage at which we become aware of it. But there are things that we can do things about, which improve your well-being, which also, and when your well-being is improved and you have high motivation, you have high engagement, then you comply with all the exercise of nutritional advice that you’ve been given. And all in all, pre-habilitation, this targeted intervention acts by acting together. So you can then improve your functional status, which goes on with the major hit that you may have as a result of treatment. Going down in your healthcare-related quality of life, you can come back quicker with lesser complications. And when we say exercise, it is not just telling someone who has just been diagnosed with cancer, who’s in a very vulnerable position, who’s psychologically devastated, and they’ve got a hundred things to do to just go for a walk in the park. That’s a good starting point, but we need to support them to tell them the type of exercise they need to do. That is dependent on their clinical need. That depends on what their starting point is. And it often depends on the kind of treatment they’re going for and how far away is the treatment from starting. So public health measures, for example, often talk about physical activity, about walking groups, about cycling groups and things like that. But unlike public health measures, we don’t often have six months, a year, two years, to design a treatment to have an impact.

Prof Tara Rampal
We are very lucky if instead of six months, we get six weeks before the treatment starts. Sometimes we get 10 days before a treatment starts. So we need to look at what kind of exercise and then support people and monitor them and to ensure that they’re able to comply with the exercise that they are giving. Then you look at the nutritional component of pre-implantation, focuses mainly around nutritional deficiency, protein optimization, and then comes the most crucial element, and I think to a certain degree quite understudied element, and which you may have referred to as psychological support. And the psychological intervention can range from talking therapies, cognitive behavior therapy, focusing on anxiety, depression, acceptance of the diagnosis. And this is not just an independent marker of the patient’s outcomes, but you need psychological support to comply with the exercise advice that you’ve given to patients as well. It is a very challenging time, and it’s almost like we should be giving people a handhold to help them navigate the treacherous parts and come out at the other end stronger. There are two challenges you often get. You often get told that, oh, there is not enough time for the treatment. I only have a week or something to start. But let’s start. Let’s see what we can do. And the person in front of you is the person in front of you you have before the start of the cancer treatment. Let’s work with what we have. We don’t have the luxury of six months, so be it. We can design a program that helps someone at this stage of life. But crucially, what we need to start looking at is we are providing people with effective tools. It’s, you know, when you tell exercise is medicine, even when we prescribe paracetamol, we tell people how much to take, how often to take, so they do it in the right way. It’s beneficial to them and don’t end up having risk factors. Yet when it comes to exercise, we don’t tell them how much to do and how often to do. So here we are increasing the knowledge, the confidence, the self-sufficiency of people who are presented in front of us to try and increase their… So that’s where the crucial role of having a tailored program personalized to someone’s need is crucial to not just improve their well-being, but actually to improve the clinical outcomes as well, tangible solutions that we can go back to, and that can be measured effectively.

Robin Daly
Some of the things you talked about are very directly physical, biochemical, all the rest of it. You can see how they would act on the person’s background health. You’ve talked quite a bit there about this psychological side. My bet is that this part of it is actually maybe the most important part of the whole picture. You’ve given examples of ways in which you could provide psychological help, but something I want to bring in from my own experience is that one of the differences, what I’d say was a massive difference in what you’re talking about between that and the conventional approach, is the conventional approach says, there’s nothing you can do, we’re going to handle it all, just turn up for your appointment, pull it out, and put up with the treatment. Now, you’re saying to the person, actually, there’s something you can start doing today which is going to have an effect on the outcome of your treatment potentially. It’s going to be your input into regaining your own health. The psychological impact between the disempowerment of being told there’s nothing you can do and the empowerment of being said, oh yeah, there is something you can do. Here’s the evidence that shows how well it works and this is exactly what you should be doing given your circumstances. Those two are like night and day to me psychologically.

Prof Tara Rampal
I couldn’t agree more because I think it’s it’s offering joint authorship in the story of your life. It’s almost as if like you mentioned disempowerment, you know, and it’s almost when someone is like is psychological security and the confidence of knowing that I do have an active role to play And I feel like that is the most engaging and motivational moment and I think sometimes we forget That people who get to receive this diagnosis of cancer and their family members now They’re at crossroads and they would they’re actually gearing up to do whatever they can to have really good outcomes it is a very motivational point in someone’s life and And at that point if we actually disempower them and say well Okay, and I’ll see you in two weeks turn up to the department to get some you know That is not the way forward. I think we often and myself as a doctor We as clinicians are very guilty of looking at people occasionally us Almost solitary hanging in isolation elements. Whereas people are some of their experiences they have their whole complex psychosocial needs and their life they come with their life and We need to start looking at people as people with whole lives, you know But not not just hanging in isolation following a clinical path and I think rehabilitation will be a long way once it gets accepted standard of care And when people are aware of it and I know with it, I think you mentioned psychological support I think they’re a wonderful thing which we offer we are proud to offer is the peer support, you know Because nobody understands I can pretend to understand that someone else would have gone through and yes I have some experience my personal experience of cancer journey that my mother But everyone’s circumstances are different and I can’t just pretend to understand what you’re going through but someone who’s gone through probably similar set of operation similar set of treatment same juncture of life will be a much better person to offer the psychological strength and the safe space to offload your anxieties Than anyone else and I’ve peer support is again, like you say sometimes we tend to write it off, isn’t it?

Robin Daly
It’s really important, you know, peer support and group support are two things that, you know, we’re the charity, are getting more and more engaged in because they have so much to offer to people. So, yeah, absolutely agree with that. Okay, and just to get off on a bit of attention now, so I understand you’re in the needs of this. It seems to me to be a bit of a leap to rehabilitation. What happened?

Prof Tara Rampal
this is not the first time I’ve encountered this question. So as an anesthetist, I think I have a unique perspective, you know, I can see people and I can see the relationship between someone’s preoperative status and the complications that they may have after an operation and, um, a few years back, what used to really frustrate me is not being able to, to see that sometimes people are not able to tolerate the most aggressive form of surgery, probably because of having low baseline functional capacity. And I used to feel that there must be something we can do to make them fitter, to take on the challenge of, uh, this operation that they are having. And also it’s a very esoteric thing. And you said off tangent, but it also offers being an anesthetist also offers a huge position of privilege. People listen to you when you tell them what to do.

Prof Tara Rampal
Yeah, so I think, and what do we do with that position of privilege and responsibility, you know, we need to, it is almost a moral onus upon us to then use this position to offer people tools and offer people the right point them in the right direction of things that they can do to improve their outcomes. that is where my interest started in prehabilitation with just pure surgical prehabilitation pathways. And then through a lot of research, through a lot of collaboration, you know, it expanded into the realm of cancer prehabilitation, where most of the evidence seems to be coming from for prehabilitation. I’m very proud to have gotten involved. I think it makes me a better niche just because I have stopped looking at people as just isolated incidents in a patient care flow pathway, and I’ve started looking at them as complex individuals like we all are.

Robin Daly
Cool, very interesting, maybe it’s a good moment just to mention what you’ve set up, quest pre-hab.

Prof Tara Rampal
Yeah, so Quest Prehab is essentially digital pre-habilitation. So I think that to offer a multidisciplinary, personalized, and sustainable service is expensive. It’s not just the need to have a dedicated workforce to provide the additional service, but there’s also resource requirements if you want to offer traditional face-to-face service of space, equipment, infrastructure. What I also started looking at was a face-to-face service often also has organizational boundaries, you know, so it can only be offered which leads to inequitable access. And also it may tend to preclude people who need to take time off their work commitments if it’s only available during weekdays or in a certain way people from the socioeconomic, poor socioeconomic backgrounds, due to the opportunity cost that is involved in travel, childcare costs, and the ability to fit in the session through regular hours. COVID-19 pandemic proved to be a catalyst to set up a digital pre-habilitation service. And that is what Quest Prehab is. This is a unique combination of the cost effectiveness and scalability which is offered by digital solutions, but at the same time maintains the crucial human component in the form of dietitian psychological support and exercise experts as well. So we have people involved which use the technological services to help screen, personalize, and tailor pre-habilitation programs of any of the patients. And because it has remote provision, it has no geographical barriers. So patients who further afield from a hospital don’t miss out and addresses health inequalities by decreasing the opportunity cost for patients and for the providers, it’s more cost-effective. So this is our experience of having a unique combination of human element incorporating technology which has made a very efficient service which also has clear impact, which we have highlighted in patient experience, in patient-reported outcome measures, and quality-adjusted life years for the patients as well.

Robin Daly
Okay, well, we’ll pick up the URL for that at the end of the show and so back to preabilitation, you’re making the case for improving wellbeing before counter treatment, but it’s fair to say there’s probably equally compelling reasons for lifestyle interventions such as the ones you’re promoting during and after treatment. Indeed, if you haven’t even been diagnosed at all, would you agree with that?

Prof Tara Rampal
No, absolutely. Absolutely. We need to look at what we’re trying to do as a tool to address population health needs in the sphere of population health. And, you know, depending on surgical treatments for cancer, have a definitive endpoint in a certain way. So prehabilitation can be designed just to go in diagnosis and just before. But when we have people who are going for monotreatment, they’re undergoing chemotherapy, they’re going to radiotherapy, then we hold their hand throughout the treatment because their psychological status mainly differs from week to week. You can’t just abandon and halfway through. There might be treatment changes, treatment related complications. There might be pauses and restarts. It needs to go on. And when you say even before or before any diagnosis, yes, 100 percent, which is a tool for population health. And what we think is this cannot be quantified, but this is just our experience. If you provide these tools to one member of the family, slowly the whole family changes its behaviors and they start adopting healthy behaviors and living handily. I’m sure you’ve encountered that in the multitude of patients you’ve met. The only successful element, one, I think he has pre-diagnosis, pre-screening is important, but the one element that the success of a cancer prehabilitation treatment is hugely, we should be attributing to is the patient motivation.

Robin Daly
Yeah, I think you’re right here. Obviously, a diagnosis is a major life shock and it does produce this thing called the teachable moment when people are open to making changes they wouldn’t necessarily be open to. And yeah, once done, that can be infectious. Yeah, you can spread that around your family and friends as well. And so it is a great in road into that. But, you know, the, the situation with cancer actually is an emergency right now, you know, it’s the sort of thing that should be on the news every day, like COVID, because of course, it’s killing more people than COVID ever did. And the stats are so bad now, we’ve hit this milestone of one in two people getting cancer in their lifetime. And the next milestone can’t be that far off with the exponential rise in incidents that’s going on, going to be that we all get cancer at some time. And after that, we’re going to start measuring, well, how many times? And so kind of, we absolutely desperately need tools to move the needle the other way, away from cancer, and to build a good resilience and immunity. Well, that’s not a pharmaceutical intervention. This is about healthy lifestyles. It’s about getting your your baseline health up. So what you’re doing in a way is a pilot for what’s needed for the whole population. Okay, it’s a great opportunity to use it with people with cancer. But this science view like of getting populations to change their behavior for their own benefit is it was it’s a young science that we don’t understand very well at the moment, look at the obesity problem.

Prof Tara Rampal
it is I mean like with the cancer incidence I think one more encouraging thing is that people are living longer, you know with cancer as well But we are living with and beyond cancer in a certain way or just living with cancer And you’re absolutely right. We need to be looking at these measures and incorporate and embed them with our population and You mentioned teachable moment and i’ve often thought other is that a little bit? are we do we really need to teach people because I think people are very well aware So I think it’s more intensive Intervention which is needed for people actually Because you your whole world has shaken you received a cancer diagnosis. You’re thinking is my well done How do I tell the children? What are the next steps, you know as for my home insurance mortgage? What are the implications how are they coming? And on top of that, you know all this pile of information it is a lot to take in as well The whole family is in shock. We need to at this point almost Say well Yes And let’s see what else at this point if we just tell them and also go for a walk twice a day while it is A very good robust advice I don’t think it will make a discernible impact between now and the two weeks down the line when the treatment is stopping And hence I would say that while we are doing population health strategy brilliant But we need evidence-backed very intense and targeted intervention for every individual, you know because Once need is different, you know, you might for you going for a walk You might be something you already do every day. You’ve got a dog that needs walking twice a day So you might that is not going to make a discernible impact on your health status at that point So for me, it is very important is that it’s almost like involving people. What do you like to do? Do you like to go for a swim? Do you like so that is we can design the program around you and it is intense enough to make a discernible impact in the few days and then You know so that I think there is a slight difference in there the intensity and personalization So we sit in our little bubble sometimes and make these kind of statements or have these kind of biases and we need to Or develop ourselves as clinicians flexibility of mind First to recognize that people are very savvy very intelligent and they will cope with what we give them But also to have the flexibility of like you say that Lifestyle interventions are equally important besides the hardcore traditional. We are not replacing No, we add you on top. We’re adding on top. There is no way as I need to as well I say that ever replace the curative surgical treatment No But to have a better outcome from that surgical reception you need to recognize and the first step is It’s almost like it’s coming up to christmas. It’s like miracle on the 34th street. You need to believe That these are important yourself. Yes first you start eating only then can you start convincingly telling a patient? And helping them access this if you’re just doing a tick box and say and by the way if you go for a walk It’s good as well. That’s that’s what

Robin Daly
No, I absolutely agree with that. The thing I’m thinking about this whole approach is that it’s very, you know, medicine in general has been about fixing things, you know, dealing with symptoms, all that kind of thing. And this is promoting health. It’s quite a different action, in fact. And it is different skill sets, different people involved. And it also involves investing in people before they’re ill, essentially, or before something. Anyway, you’re actually trying to avoid things going wrong, which is very different than just picking up the pieces all the time. But it seems to me that it’s crucial that the government thinking the image is thinking moves into this area of trying to keep people well. Otherwise, we’re going to be overwhelmed by people who got things wrong, where it’s already happening, you know, and it’s getting worse. So this helping people learn how to keep themselves well is like vital for the for our future, it seems to me. So you’re piloting something there, which is I think it’s, it’s got lessons in it for the whole of health care really is to a new, it’s not like you don’t need to be able to pick up the pieces, I’ll always be there. But actually, a huge amount of emphasis is to move across into this health promotion. That’s how it seems to me. What do you think?

Prof Tara Rampal
I absolutely agree. Sometimes if you think traditionally, like you say, our focus has been on fixing things, offering an intervention for what’s broken. When you have an intervention like prehabit, which looks at something that didn’t happen, it’s a complication. It’s very hard then for people who have the authority to commission services or to then put a figure to it, because we can say, yes, your surgery cost is this much, but how do you put a figure on the complication didn’t happen? I think we need to start moving from the mindset and the help of the population and start looking to put a… I find it very difficult to say the words like put money and figures, but like value, value on the intervention that you’re offering for the health of the population. We need to start valuing that more than just interventions. I would really like to think that the way our healthcare is moving beyond the organizational boundaries, looking at integrated care boards, that this is a very good opportunity to start looking at value of the interventions, which come in the preventive stream, like our grandmothers used to say, stitch in time signs line. That kind of thing. We need to start putting values on things that are preventing any complications and increasing the health of the population. I think these components, both as clinicians and people with healthcare policies, there has to be a marriage of these, a happy union, a happy marriage coming together to work towards the same goal.

Robin Daly
Yeah, so we need people, patients to be working with developers and clinicians to come up with good solutions. Absolutely. And looking at that whole value thing, I think it’s really important to remember that when somebody is in hospital being treated, they’re a drain on the society as a whole, they’re being supported. But they’ve come from being somebody who’s actually a supporter is producing the parts of the whole benefit of the nation. So to move from a positive to a negative like that is a massive move. It’s not just like from something positive to nothing, it’s actually from something positive to actually taking money out of the system. And so the win from keeping somebody healthy and well is actually sort of double what it appears.

Prof Tara Rampal
people don’t want to be in the hospitals, you know? Nobody wants to be in a hospital.

Robin Daly
No, it’s a win for everybody. It’s a win to the health service, a win for the public. Yeah, absolutely right. So anyway, you’re on a mission to get the word out there about the importance of rehabilitation to cancer outcomes. So what are the challenges? What are the key obstacles that you’ve got to overcome?

Prof Tara Rampal
How much time do you have?

Robin Daly
The quick answer, because we’re nearing the end of the zone.

Prof Tara Rampal
Jokes apart. I think you know one of the first thing is very hard to quantify like I say the value of something that didn’t happen So that is very very difficult to do that. And I think any the second challenge also has been that You know, sometimes we are very reluctant in any large organization For example to accept solutions which were not developed within the organization itself So, you know, like if we we need to you know Organizational boundaries now for a person on a cancer care pathway from the time They picked up the phone call to serve to the GP to say they felt a lump in their breast to actually ending up on The operating table pre-imitation can be offered at any point and it is best offered in the community in their home And so we need to move beyond that every intervention has to be developed within our hospital I think that mindset and accessing that with the clinicians that there we need to look at the impact We need to look at the effectiveness and we need to look at the value of taxpayer for the money for the intervention being offered Our North Star always has been patient outcomes and working towards this I think in patient partnership The challenges should be surmountable. I’ll come back in two years. I’ll tell you

Robin Daly
I can see a very useful role for GPs here, you know traditionally GPs, they get as far as saying somebody should go and see the specialist and have it checked out, they diagnose the cancer, that’s the end of that. They leave it to the specialist after that and GPs now have a new tool in the toolbox which is social prescribing. Social prescribing is for a whole range of lifestyle factors exactly like the ones you’ve been describing. They could be you know key players in making sure that the patient gets rehabilitation as soon as they’re diagnosed along with many other things during treatment but there’s generally this kind of hands-off leave it to the specialist thing going on. Is there a way of changing that?

Prof Tara Rampal
I think our GPs are under incredible pressure. You know, there is each year we know the kind of clinical and the workforce challenges that they are facing. So I think anything that we can do as people who design services that helps ease the pressure on them would be the way forward to get the engagement, because, you know, while I think they are the pivot around which our NHS evolves, the entire health service revolves and we should create solutions where they can have faith that the service will deliver and then they can just refer the patient to the prehabilitation services. So I think, yes, together with the GPs, we should start working towards because they are the person that the person knows, the patient knows. They are the linchpin health care.

Robin Daly
They’re probably the entry points as well.

Prof Tara Rampal
the more often that people hear the word prehabilitation, the more, you know, like if every contact counts to get a deep seated and the more upstream the patient care pathway it is, the better the results and the engagement would be. So definitely collaboration with our primary care physicians, our primary care networks would be the way forward, work towards solutions, which are sustainable and not just pop up in the world of medical innovation, sustainable things.

Robin Daly
So, you know, you’re saying you’ve got plenty of obstacles, but my sense is that they’re more in the realms of sort of organizational change, the changes within the NHS in order that this becomes part of the norm than they are changing the public’s attitude, because my sense is that people with a diagnosis of cancer are all too ready to hear some messages about what they can do to help themselves. It’s not the public that needs to change, it’s the system.

Prof Tara Rampal
Absolutely. 100%. The public is fully on board. It’s always like, what can I do? What can I do?

Prof Tara Rampal
Yeah, to make it better and I think we at that time should be confident enough and we can’t know everything You know, we are specialists in our own field And that’s why we need to show to people who are specialists in pre-habilitation and say well This is the one thing you can do and you can start taking an active role in your treatment and No, there is the hesitancy comes generally from us on this side of the fence

Robin Daly
that’s what you’re working with basically anyway looking on the brighter side what are the what taxes do you think are actually acting in your favor right now

Prof Tara Rampal
I think the recognition of population health, because a few years ago, how many of us knew of the fact that population health existed? I think more and more global acceptance, you know, if you did a PubMed search on the field of prehabilitation in cancer or prehabilitation in surgery 50 years ago, there’s an exponential increase when it comes now to the number of research, which is research, the trials that are producing results outside. So we are recognizing slowly that what we have been saying, like you mentioned, was just, you know, somebody wrote, some hippie wrote somewhere about that. We are recognizing the crucial health factors of your well-being, of your physical fitness, of your environment. All these are social determinants of health. And I would go further and say they’re actually very personal determinants of health for you and your health outcomes. So the global medical community coming together to recognize, now you don’t need to explain the word prehabilitation. A few years ago, I went to a medical conference, I would have to explain what prehabits need to. So I think slowly, but surely the pendulum is changing from very active, intensive focus to recognition that people are complex, their needs are complex, and hence the interventions should be complex and holistic at the same time.

Robin Daly
That’s a great day to end on. Thanks so much. Do you want to give the URL of your website?

Prof Tara Rampal
Yes, it’s www.questprehab.com.

Robin Daly
nice and simple. Okay, very good. Alright, thank you very much and thanks so much for coming on the show today. Professor Rampal, I love what you’re doing and I wish you every success in establishing prehab as an essential element in cancer treatment programs.

Prof Tara Rampal
Thanks very much for having me.

Robin Daly
I dearly hope the message about prehab goes far and wide, as embedded in it is the precious realization right at the outset of cancer that there’s a lot that people can do to help themselves, and the success of one lifestyle intervention tends to quickly lead to others and to an increasing interest in integration. Thanks so much for listening today, please make a point to joining me again next week for another Yes to Life show. Goodbye.