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Thinking outside the box: Delivering lung cancer outpatient clinics in a rural and remote area

Dr Robin Ghosal is a consultant in respiratory medicine and clinical lead for lung cancer in Hywel Dda University Health Board. In this blog, taken from our recent report on innovation in west Wales, Thinking outside the box, he discusses how staffing shortages and growing waiting lists led to a new approach in how his team provides lung cancer clinics across a large rural area.

The further west you travel into Wales, the more difficult it is to appoint specialist and consultant doctors. Hywel Dda is a big health board, much of it classed as rural and remote, and there is a real danger that the lack of access to specialist healthcare could exacerbate health inequalities. 

Between 2013 and 2018, the lung cancer service in Hywel Dda was managed by three consultants with a subspecialty of lung cancer. A fourth physician was based at Bronglais Hospital, mostly focused on general medical and respiratory cases. There was no respiratory physician at all in Withybush Hospital, which meant that we had to travel a great deal to other sites using a rolling rota, and we were never in the same place for two days running.

These are big distances to travel, and the days were long: often we were the first respiratory physician they’d seen in a week. It became unsustainable and burnout became a real issue; there were inconsistencies in the direction of travel for the service and it was confusing for the clinical nurse specialists (CNSs) when different consultants took different approaches to patient care.

Admittedly, with three of us working together, it was helpful to share good practice and discuss complex cases, and we were able to offer same day diagnostics for many patients. But the travelling for both staff and patients was inefficient, we had limited access to digital technology at some sites, then we lost a consultant to burnout. So as case numbers were going up, we had fewer doctors: only two consultants really, covering four hospitals.

We stopped visiting Withybush. We just couldn’t do it. We couldn’t offer same-day diagnostics at Glangwili or Bronglais, which meant that we were offering patients a different standard of care depending on where they lived in the health board, resulting in inequity. The optimal pathway at the time was daily specialist MDT clinics with same-day diagnostics, but that model had plenty of funding and staff. We wanted to do our best, but with such limited resource, it was becoming more and more difficult.

Then we lost another consultant. Now we were down to a single consultant covering the entire health board, supported by a general physician in Bronglais. The team was broken. The relationship with the CNSs was fraught. Without enough radiologists, I was being sent thoracic imaging. The service had gone from great to poor within a few years, not because of the people, but because of the circumstances.

The pandemic didn’t help. Patients didn’t see their GP during COVID-19, so they presented later, often with stage four lung cancer, which meant more hospital admissions. There was huge patient inequality, and no light at the end of the tunnel. There was no knight in shining armour waiting to rescue us: we spent months trying to recruit.

So, we turned to technology, and we upskilled our colleagues. We have trained our CNSs and our SAS doctors to work alongside me to deliver a lung cancer service. There is now a clear vision for the future of the service. We want patients to get high-quality care, no matter where they live: they will get the same care on the same pathway.

Now we run three clinics a week. We have hybrid clinics in PPH and GGH, with some virtual appointments and some face-to-face diagnostics, and we have a Withybush clinic that is completely virtual. We meet with the nurses three times a week to support them, answer questions and discuss complex cases. We track every single patient on the lung cancer pathway to avoid delays and reduce waiting times. In Withybush, if a patient needs a face-to-face appointment, they see the specialist lung cancer nurses in person, with the doctor joining the conversation virtually. They can see the scans on the computer, and they get a clear plan of action.

The feedback from the nurses has been excellent and the patients love it. There’s less travel, they are supported with the technology, it reduces clinical inequalities, and it gives smaller, local hospitals a really important role to play.

With a single consultant lead, there is a consistent thought process. The nurses feel supported; they are the bedrock of this model of care. There are some great training opportunities for juniors and SAS doctors. It allows for cross-site working and helps facilitate research. The downsides? It’s very specialised, I’m very focused on lung cancer now. It's really hard as a single-handed consultant. Burnout is a real problem. The changes happened overnight which was tough, and the patients never stopped coming through the front door.

It’s much more enjoyable now. It’s no longer a difficult battle. Most importantly, there are very few negatives for the patients, and we’ve learned that it is possible, even with scarce resource, to deliver a quality service over a large geographical area. Ultimately, you need to build self-resilience and look after yourselves and your mental wellbeing. Embrace technology, build a strong multidisciplinary team and focus on what you want to achieve, and you can reduce those health inequalities – which is the single most important thing we need to do in Hywel Dda.

Dr Robin Ghosal 
Hospital director, Prince Philip Hospital
Consultant in respiratory medicine
Clinical lead for lung cancer
Hywel Dda University Health Board