Last week, a draft national service specification for acute oncology services (AOS) was published for consultation by the Wales Cancer Network.
In this blog, taken from the RCP Cymru Wales report, Cancer at the front door, Dr Sarah Gwynne, clinical lead for oncology in Swansea Bay discusses how the team in south-west Wales has developed AOS over the past decade and outlines their plans for the future.
I’ve been a consultant oncologist in Swansea for 10 years. I didn’t do any AOS as part of my training; it wasn’t really a thing back then. It was in 2015 that the first AOS business case was funded – three clinical nurse specialists and a malignancy of unknown origin (MUO) multidisciplinary team (MDT). Palliative care was very involved. I think they were doing a lot of ad hoc acute oncology at the time. A couple of years later, I was clinical lead for oncology and inherited AOS and MUO overnight – it was passed to me after other staff left the organisation.
To begin with, I did the MUO work myself and to my surprise, I found I really enjoyed it. But I was single handed. We needed to stabilise the service, so if I was on leave, the on-call consultant would cover the MDT and referral. Eventually the MUO work was recognised in my job plan. The MUO MDT meets once a week and includes three AOS nurses who act as keyworkers, as well as pathology, radiology, oncology, primary care and palliative care. We’ve also set up an MUO clinic to see patients, and we’ve been awarded money through the Moondance Foundation for a radiographer to speed up treatment pathways. I now have colleagues to help me.
We’ve sometimes had to be creative with how we fund things. We’ve got a management team that’s flexible and positive about letting us move money around to build the team organically. I’m proud of the team and how far we’ve come. It’s such a lovely MDT; it’s very patient-focused and it’s so interesting. There’s a good community of practice in Wales now. The Wales Cancer Network has a malignancy of unknown origin–cancer of unknown primary (MUO–CUP) working group which provides peer support.
MUO can feel like the poor relation, but we have a fantastic team of people who really see the value in this work and want to provide excellent patient care to those people who might previously have fallen between the gaps in the system. I can’t believe we went this long without an MUO service really. Patients would have been bounced around the system. Their experience and outcomes would have been much worse in some cases.
We offer clinical advice to the Hywel Dda University Health Board AOS nurses, but we’re not funded to provide an MUO service. We’re keen to create a joint MUO MDT in the future though, and we’re costing that now. It’s complex. Under a long-term agreement, we provide cancer services to Hywel Dda, but where there’s new and innovative work, like an MUO service, we need to agree separate funding with them. It’s very difficult. We don’t want to ignore Hywel Dda patients, and I will discuss them outside of MDT on an ad hoc basis, but there is no formal arrangement in place. Because of the case mix in Swansea, we know that there must be patients who would fit into an MUO service if it existed in west Wales.
The challenge now is what that MUO service looks like across four sites. There is an oncologist based in Bronglais Hospital in Aberystwyth, but she has no capacity to support any other hospitals, so where do you base the MDT and the MUO clinic? Other health boards in Wales have identified a non-oncology AOS lead in their health board, but Hywel Dda have not managed to find anyone yet. Getting patients in west Wales access to our MUO service is an absolute priority.
In terms of AOS, we have three nurses with consultant review once a week at Morriston. For a while we had clinical fellows on the service, but we didn’t have enough time to mentor and support them. More recently, we’ve been able to allocate some consultant and specialty doctor time and now we have three funded sessions a week in Morriston to support the AOS nurses on a 5-day rota.
Pre-COVID, we ran educational sessions to raise awareness of acute oncology, but a lot of that stopped overnight when the pandemic hit. It’s an ongoing battle and very time-consuming, especially when doctors-in-training move around so much. The reality is that we’re often just firefighting, given the rise in patient demand, and we’re expecting Morriston to get busier when the acute medical take consolidates on one site.
For years, we were under the impression that the plans included a specialist cancer centre on the Morriston site. More recently, we’ve learned from the new chief executive that there’s no funding for a new centre, and we’ll be staying at Singleton where the vision is for a centre of excellence with cancer surgery on the Singleton site. It was a real blow at the time, but at least it was honest feedback which means we can plan, and I do feel we are being heard.
The Swansea Bay reorganisation includes lots of same day emergency care (SDEC) and we felt that we needed more specialist nurses on the ground to support the medics with expert decision making. We also need to set up hot clinics to see patients within a few days of discharge from SDEC. To deliver this, we’re recruiting senior nurses and physician associates, and we’re putting in place a senior AOS nurse manager to lead the nursing team and develop the hot clinic model. Finally, we’ve had 15 consultant oncologist sessions funded as part of the redesign of acute medicine, which will hopefully give us some flexibility and stability to expand and develop AOS. It’s exciting.
We’re also hoping to create a clinical navigator role to triage patients by phone, sending them to either the emergency department or ambulatory care in Morriston, or the assessment unit in Singleton. Those calls currently come into the on-call registrar, which isn’t the best use of their time. Once this is all bedded in, we will look at introducing 7-day working in line with other services.
Recruitment is tricky. There is a shortage of oncologists, and it’s even harder in rural areas. But that shouldn’t stop other parts of Wales applying for the funding and making the business case. If you don’t have the money in the first place, you can’t recruit the people. At least with the funding in place, I can slowly start to build the team, appointing good people as they become available. In some ways, that’s more sustainable because the team grows organically and isn’t reliant on one person: it means that we’ve built resilience into the service.
Photo credit: Swansea Bay University Health Board