Case study: The Royal Marsden cancer rehab service

The outpatient oncology physiotherapy team receive referrals from other healthcare professionals including doctors, nurses and other AHPs. Patients are triaged and assessed by physiotherapists and a treatment and management plan established in partnership with the patient. If exercise is the mainstay of treatment, patients may also be assessed by a cancer exercise specialist and then the professional who is best placed continues their treatment.

'We needed to provide a greater level of exercise support, based on evidence for exercise within oncology rehabilitation' says Sarah Dewhurst, physiotherapist and living with and beyond cancer service lead. 'It took time to see how having an exercise professional would best fit within the existing service, but employing a cancer exercise specialist quickly enabled us to expand our exercise offer. We’re now working towards our ambition of providing all those with higher levels of need an enhanced exercise service, including virtual and in-person one-to-one sessions and classes to provide as much choice and personalised care as possible'

To ensure a streamlined and effective working relationship between the different professions, the team developed a shared understanding of governance, quality assurance, safety netting and good communication. This has been vital in enhancing trust between all professions.

The cancer exercise specialist (Adrian Fautly) has an MSc in clinical exercise science, BSc in sport and exercise science, and level 3 – 4 qualifications in cancer rehab, cardiac rehab, personal training and exercise referral. With his skillset he manages his own caseloads independently. Several physiotherapists within the team have additional MSc-level exercise qualifications so there is overlap in skills. 

'Exercise provides many physiological benefits for people with cancer. However, patients may have significant co-morbidities and are at high risk for exercise because of their cancer and its treatment so they need a physiotherapist’s input to discuss programme modifications to reduce that risk ' says Cathy Sandsund, physiotherapist. 'Our breadth of knowledge means we are well equipped to do this and can offer other treatment techniques alongside exercise. Some patients can be managed from start to finish by our Cancer Exercise Specialist and others see both professionals as their needs require both skillsets.'

Successful integration of Adrian’s post into the service has relied on good communication, mutual respect and recognition of all professions within the team. Everyone has ample opportunity to work, and learn together. This includes in-service training and multidisciplinary discussions about complex patients. They also work together on service development projects and publications.

The wider cancer service at The Royal Marsden includes support workers and clinical exercise physiologists, so several team members deliver exercise advice and testing allowing patients to benefit from reinforced positive messaging about physical activity and exercise.

Adrian says 'My role allows the physiotherapists to focus on patients who need their skills the most. The additional capacity and my exercise focus means I lead a pilot scheme taking patients into the local Everyone Active gym, the Phoenix Centre, to support the transition to exercising in community facilities. We hope the expansion of our exercise offer at the latter stages of rehab will lead to more successful discharges into the community and reduce the demands on future health and social care services by embedding the activity habit in patients’ daily lives.'

Adrian is eligible for the new Registration Council for Clinical Physiologists (RCCP) registration and is undergoing the registration process. 'For me, physiotherapists are experts in pathology, pain management and red flag screening. My deep understanding of exercise physiology, cardiovascular considerations and how they should be applied clinically complements their knowledge perfectly. We have confidence in our overlapping skills and an appreciation of each other’s areas of expertise and when a patient would benefit from someone else’s input'

James’ story

James* received input from both the exercise specialist and a physiotherapist when he developed foot drop. 'I was having general exercise sessions with Adrian for strengthening and to restore the fitness I had lost through inactivity during my cancer treatment, when I developed problems with my foot due to nerve damage'

James was seen by a specialist physiotherapist during his usual exercise sessions to ensure continuity in his care and avoid the need for additional visits to clinic. The physiotherapist provided guidance for foot drop including targeted exercises, therapy and splint provision, reinforced with written and video versions of home exercises to encourage self-management.

'My treatment always felt joined up because the work I did with Adrian appeared to be linked to the physiotherapy treatment and communication between staff was excellent – they always had clear goals and a plan to get there that I was part of. We very much worked together. I’m more aware of what type of exercise I need to do long term, and through a 6-week programme in a gym in Surrey with Adrian, I plan to continue exercising with the support of the gym staff.'

_{*Name change to maintain anonymity}

Benefits of collaborative working with exercise professionals

Key learning points

• Clear governance and safety netting around the employment of exercise professional
• Treat all team members as equals regardless of profession and value input across all pillars of practice.
• Dedicated time together for CPD, handovers, joint sessions
• Open channels of communication