Episode 121: In the Clinic - The Acute Oncology Service - Cancer's Front Door Heroes with Dr Caroline Wilson

AOS Simply oncology podcast-20260803_120542-Meeting Recording

Mike, we are back for another Simply Oncology episode. This time, what does every patient, if they come into hospital, who are they engaging with? Mike? John, the first is the acute oncology team. And the acute oncology service, that is when things are going wrong and you need to come into hospital, This is a relatively new thing, depending on your age, but probably about 15, 16 years old. So we've got the wonderful Dr. Caroline Wilson from the Christie in Manchester to come and join us to tell us about her experience with acute oncology, what it is, how it's going to evolve further. and what they do to support cancer patients. Caroline, welcome.

WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 3:33 Thank you. Pleasure to be here. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 3:35 Caroline, could you give us a bit of your background in the acute oncology sphere, please? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 3:40 Yeah, so I probably am regarded as an elderly acute oncology consultant as I've been doing it for about 10 years. So I can remember back to when NCPOD brought out that publication that said cancer patients if they're admitted under care and to other areas that are not in under oncology get a worse deal and they are over investigated, they stay in hospital longer and their outcomes aren't as good. So that was very much the catalyst that 15 years ago said we've got to change. So acute oncology then at that point was quite organic in how it developed. We didn't have a national service spec, so each acute hospital that had an A&E suddenly had to develop an acute oncology service. So it was set up very differently across the UK. But I've been in acute oncology now for 10 years and kind of seen a huge change that also feels at the moment that the rate of change is accelerating because we've got the cancer plan, because we've got the NHS plan. Big, big changes are coming and they are the right changes and acute oncology has to get on board with that. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 4:25 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 4:45 You know, we've had very, very patchy cover. So some of our acute oncology services are predominantly nurse led services and the majority of them are still running on a five day service. Well, acute by definition is not a five day service. It's A seven day service. So we don't have equity across the ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 4:55 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 5:04 devolved nations either about whether you're having these services five or seven days. The ability that those nurses have to escalate to senior decision makers is really variable. So some of them don't even have acute oncologists because there are no acute oncologists in that local area. They just have to go through to on call. So that may be an on call consultant who's been doing GI oncology for the past 25 years, an older consultant who's a long, long time out of doing their acute medicine and may be really quite uncomfortable giving advice on complicated toxicity in another tumour group that might be a lung patient admitted to a local hospital. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 5:39 Mmh. This feels very familiar, Caroline. This feels very familiar. It's like you've been watching our on call. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 5:44 Yeah. And I think this comes into, we've got to start being realistic about who is trained to manage these complications. You know, there's been a huge piece of work done led by Kate Young at the Marsden with the UK Acute Oncology Society Group, with the RCR and the ACP to get ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 5:49 If. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 6:07 a description of a job plan for an acute oncologist. It is a subspecialty. You should train in acute oncology like you train to be a breast oncologist, like you train to be a GI oncologist and you should be doing your continuing CPD every year and at your appraisal proving that you're competent to be an acute oncologist every year because we are the ones that will have that. Support and knowledge. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 6:31 I am gesticulating because I want to interrupt. There will be people listening going, so what is acute oncology in a nutshell? You've told us why it came about. It came about because people admitted under endocrine teams or respiratory teams with cancer problems didn't get the specialist input, but if you were to define what an acute oncology service is, what would you say? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 6:59 Yeah, so acute oncology covers three types of patients. Your type 1 patients are your new diagnoses of cancer through an emergency pathway, not an elective pathway. So that's your patient who's admitted from the GP with suspected pneumonia found to have a lung cancer. So those are the patients we take. That's our type 1 patients. Our type 2 patients are when we look after the patients, because they have a complication of the anti-cancer treatment they've been given. So we cover those patients as well when they need admitting to hospital. And we know that around 15% of patients will need admitting with an emergency unplanned complication of SACT after a dose of SACT. So they are not insignificant in the size of the problem they are in acute care. The other type of patient we will look after are the patients that have complications of their cancer itself. So that's when your cancers eroding through organs, whether it's causing pleural effusions, whether it's causing pericarditis, whatever. So it's when the cancer itself causes a problem. So we take those three types of patients and we have wraparound services to facilitate their management. Now if that cancer patient is being managed in a cancer specific hospital, such as the Christie, such as the Mars and standalone cancer centres like CLATTERBRIDGE, it will be oncologists that are running those teams. If the patient admits to an acute hospital, oncologists are not employed by acute hospitals generally, they're employed by the cancer centres. Those acute oncologists are not on site in acute hospitals with A&E, so they will be admitted usually under medics or surgeons if there's a surgical complication. And that's where the acute oncology teams comprising of the nurses and the consultants need to help those teams understand how to manage those type one, type 2 and type 3 patients. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 8:41 So they're a bridge or a link between acute admitting services and oncology teams. They are that kind of glue to bring those two things together. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 8:53 Yeah, to get that right knowledge at the patient's bedside when they're not in a cancer centre admitted under an oncologist. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 9:00 And where do you see that relationship ending? Should it be an initial contact and then back to the specialty team? Or is this a throughout the admission journey ongoing input? What's the best practise? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 9:14 So I think this brings us into a conversation about what is changing. So traditionally, when I first started acute oncology, we would see patients that were in an inpatient bed, they had to have got through the front door and been put into an inpatient bed and we would support the type ones, type twos and type threes of the inpatient cohort. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 9:18 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 9:36 Now this is changing because we absolutely have to start keeping cancer patients out of hospital beds. You put a cancer patient in a hospital bed, they go sarcopenic, they decondition and then they are far less likely to get back onto their anti-cancer therapy due to the deconditioning of an acute admission. We need to keep them at home, keep them moving and keep them fit for the next treatment. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 9:42 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 9:57 So there's a big swing and this all very much aligns with that NHS cancer plan about that hospital to community. So we need to be at the front door. So rather than waiting for these patients to come through and be admitted, we've got to try and be at the front door to make those decisions. What we know, and there's very clear data, that if a patient goes to an acute care setting for their initial assessment versus an oncology run unit, the oncology run unit is far more likely to ambulate the patient and send them home than acute care will. Because of this concept that cancer is complicated, the patients are really sick, the drugs are really weird, we don't know what they are. But actually if we give the front door of acute services, A&E's, medical aspects, we give them support, they should be able to ambulate the patients as well and send them home and stop this default to admission, which gives them very high admission rates. We looked at some of ours across GM and we were, our rates of admission for common things, Greater Manchester, sorry, so Greater Manchester. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 10:55 GM. General Manchester. Greater Manchester. See, got it, got it, got it. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 11:01 So across the big region, the likelihood of admission was very high. So we were ambulating less than 15% of patients presenting with a fever when they were coming through our A&Es and RSDECs, or if they came in with a new brain lesion that weren't necessarily unwell with seizures, but could have been ambulated. And it's because ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 11:07 Yeah. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 11:20 of the lack of confidence that I think our front door acute care staff have. So we as acute oncology have a responsibility to help educate them, give them that support and be really visible for them and actually be in the front door for them to help them make those decisions. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 11:37 And so what's so in that vein, what are your thoughts on oncology specific EASTLAKE kind of, because we've got a lot of units have, you've obviously got your 24 hour triage line that's going to be triaging a lot of side effects of patients. And we're thinking particularly here about sort of management of toxicity of patients, but sometimes symptoms as well. And we, some units will have things like their assessment areas or chairs on their chemo unit. They can see people. It's loads, loads of different pathways. But ultimately, you know, we take, you know, examples from our medical team who run things like, you know, same day emergency care medical assessments. Is there a role for that in oncology? Should we be taking a lead and actually having a whole separate wing of the hospital to see these patients acutely? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 12:24 Yeah, absolutely. And this is very much what the UK Acute Oncology Society is working with the Society of Acute Medicine at present to get, we're calling them the big 5 ambulatory guidelines, and that's to support our medical SDECs to do some of this common acute oncology emergency work that can be ambulated. So the five conditions are going to be PE, They do that really well already. Febrile neutropenia, ambulatory cord compression, hypercalcemia and new brain lesions that can be ambulated. And those guidelines are three of them are already published on the UK Acute Oncology Society website and co-badged by Sam. So if you haven't spoken to your medical SDECs, you need to go talk to them about how you can help support them and get them to do this. When it comes to oncology run aspects, I think we're now getting to a state where we can quite... easily define where you need a medic to lead on the management of that patient with oncology advice and where you need an oncologist to lead in the management of that patient with medic advice. We've got to be really realistic. As an oncologist, we're not trained in general internal medicine. We never did our GI training. So when it comes to complex things like ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 13:18 Mm-hmm. Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 13:32 cardiomyopathies, if it's coming to really bad colitis, all the stuff we do get through IO. Yes, that can initially be led by oncology, but we need our medics to help us. And sometimes our medics can lead on some of the more straightforward oncology emergencies like PE, like a febrile neutropenic, but they may need a bit of oncology advice. And That's very much what Sam and the UK Acute Oncology Society are trying to do to kind of explain some of the conditions that could go through a medical EASTLAKE with oncology support and then the other more complicated things are probably going to need to stay within an oncology EASTLAKE, but we're going to need medical specialties to support us. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 14:09 Absolutely. And just for Mike's benefit, Sam is so sorry. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 14:14 Society of Acute Medicine. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 14:15 That's what I thought it was. So it sounds like oncology needs to take a lot more of a point on this. And you've made, you've commented before on the fact that there should be better training within oncology for this subspecialty called acute oncology. Because what a lot of centres will run on is an on-call service for oncology. either through clinical oncologists or medical oncologists, supported by clinical oncologists for radiotherapy issues. What is the, what is, first of all, what's the difference between your model and the current models and what needs to, how much change needs to happen? Because in my mind, you've got, for example, we have 13, 12 or 13 consultants here on a rota. A 10 or 11 on a rota doing one and 11. How does that work with an AOS service? Does AOS then replace on call altogether? Does it do overnight? Does it do weekends? How does that service look compared to the current on-call services? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 15:11 Yeah. So I think it's hard to give you a one answer fits all because everybody is different. Let's start at how do you make an acute oncologist. So ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 15:18 Yeah. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 15:24 Oh gosh, I'm trying to think, when they redid all of the curriculums for our trainees, which was, it feels like it was about five or six years ago, it very clearly went certainly into the med onc curriculum. I'm not sure it was quietly as explicit in the clinic curriculum that acute oncology training for our trainees is not on call. Being on call is not enough to train as an acute oncologist. So they had to have ring fenced acute oncology time within their training to prove that they were AO competent. So that might be, for example, running an acute oncology hot clinic. It might involve time on an acute oncology SDEC unit, but it's not being on call is not enough to gain the knowledge and experience in acute oncology. So that goes back to our training level. And it was actually really important when that when the curriculums were changed, was at a time when NHS England was very keen for every subspeciality to be GIM accredited. And you'll remember our palliative care colleagues ended up being GIM accredited. The only, well, not the only, but one of the very few things that saved oncology from being GIM accredited was that we ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 16:23 Oh, I remember that. Yeah. Yeah. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 16:35 provided acute oncology support. So we provided support for the acute take already. So it was the fact that we were already doing this acute work meant that we didn't then have to have our trainees going through a dual accreditation. So that's when the training was made a lot more explicit in the curriculums. How each centre has implemented that ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 16:43 Okay. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 16:55 in terms of training our edges is very variable. So For example, in the centres I've been in, the regs have had allocated AO time, they've done AO hot clinics, they've been on the oncology admissions unit on a rotational basis, which is outside of their on call. The second question you asked is, does AO take everything away from the on call? I don't think that's possible because of the workforce shortage we've got in oncology. I think what AO can do is that in hours management of the emergencies and take that completely away from site specific, ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 17:18 Mm. Mhm, mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 17:35 So what I'm talking about there is like, like the SDECs do, they usually open 12 hours a day and then they vary somewhere between 8 and 10 hours, sometimes the 12 hours at a weekend. But AO take that service like the medical SDECs do. So you take that management of oncological emergencies and that's run by people who are experts in running that service. When it comes to your 9 o'clock at night to 9 o'clock the next morning, that is so much harder because we just don't ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 17:53 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 18:00 have a workforce that can provide a 24 7. So we're going to probably always have to have an on call to cover those. And that's probably going to have to be an on call that's shared between everybody, whether you're an acute oncologist, a breast oncologist, a bowel, just because there aren't the numbers of us in each place to provide that 24 hour service. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 18:01 Mhm. You can. And you've mentioned that how it's evolved. You also dropped the immunotherapy bomb at one point when you were chatting. I think it has to be said immunotherapy has led to a major uplift and an upscale and just a massive increase in awareness in acute oncology services because it has brought us directly in line with so many specialities when you get an IO toxicity of colitis, pneumonitis, any of the itises, We're then having this crossover. Is that immunotherapy revolution? Has that now, has that now all settled in and we're now looking at ADCs as the new toxicity that's on the AO horizon or are we still trying to get everybody up to competency with immunotherapy toxicity? Management. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 19:15 So I think, I mean, I've seen over the past 10 years such a change. So the majority of AO, if you're talking about the type 2 patients, so they're the complications of the treatment the patients have received. Let's talk about type twos. You know, 10 years ago, it was it was usually capecitabine. So it was it was your good old fashioned chemotherapies that caused the toxicities that the patients are coming in with. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 19:27 Yes, yes. Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 19:41 Then if we go back to about five years ago, IO at that time in the whole scheme of AO was still only about 10% because we audited it across South Yorkshire and looked at how much was pure IO tox versus everything else that we give. So our tyrosine kinase inhibitors, our chemos, and AO was still only about 10%. And I don't think that percentage, I haven't looked at the data in the last year or so, But that when I look at my acute oncology daily MDT data, it doesn't feel like it's hugely. bigger than that. And I think that's because a lot of the times our IOs are going in combination therapies and it's actually usually the chemotherapy partner that is causing the problem that the patient comes in with. I think where IO is causing a big problem and we have no resource is the time it takes to sort an IO out. You know, it takes a very short amount of time ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 20:19 Okay. Mm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 20:33 to stop someone's chemo, to reverse their febrile neutropenia, to get them sorted and they're okay. IO is more complicated because if they need an inpatient stay, they really need an inpatient stay. If they are steroid resistant, you're into all of your second line immunosuppressives and getting onto your third line becomes even harder. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 20:46 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 20:53 And then when they leave the building and they leave the acute setting and go home, our site specific or tumour type clinics are too busy. You can't then expect your poor renal consultant to manage ongoing acute talks at home through a renal clinic because they're too busy doing their renal clinic. So I think that's where there is a big gap. It's that semi acute management where the patients fit enough to get out of hospital, but still needs really close monitoring in terms of their doses and their reductions of their steroids, etc. And that's where I think we have to learn from our acute medic colleagues and our respiratory colleagues and our frailty colleagues with things like virtual wards. I mean, virtual wards in oncology, they're just that they're a new concept and we've never done them. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 21:31 Yeah. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 21:36 But our medical colleagues have been doing this now since COVID and doing it really, really well and successfully and have entire teams, you know, of nurses in the community, consultants supporting them and managing people at home with these chronic or ongoing acute complications. And this is where I think we're going to have to branch out a little bit in oncology to deal with this. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 21:56 And how do you see on that note of sort of people potentially deteriorating in the community and sort of being able to highlight that and do something about it to prevent admissions, how do you see acute oncology services coordinating or synergizing with things like enhanced supportive care services including things like managing people in virtual wards. And then on top of that, how we bring together, because it feels quite fragmented, it feels like, because things have happened so quickly, you know, there's immunotherapies come through, but then there's now, you know, all of our androgen receptor pathway inhibitors, there's PARTNERSHIP inhibitors, there's ADCs, all of these new drugs, new toxicities coming through so quickly, no one can keep up. So we're kind of building, bolting on great ideas. I'm thinking specifically about things like immunotherapy toxicity services that some trusts will have set up as a standalone service separate to the acute oncology. Is there an argument to try and bring all of this under one group or is it or should it be remaining as this sort of bolt-on modular status that we currently run. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 23:02 I mean, I might be old school, but to me, toxicity is toxicity. So, you know, if you're if you're if you're an acute oncologist or you're a toxicity specialist, whatever you want to call yourself, you should be able to deal with all of it, whether it's an ADC, whether it's an IO, you know, you should be trained and competent enough and have enough time in your job plan ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 23:16 Hmm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 23:23 to deal with all of the associated toxicities. When it comes to how to do that in the community, this is where it's going to be a bit of a challenge because AO services are very secondary care. They have been secondary care inpatient facing. They are starting to become secondary care front door facing. We are seeing some really good pieces of work where AO nurses are in SDECs. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 23:36 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 23:44 AO nurses are in A&E with a clear reduction in the amount of admissions. So that benefit is there, but you're still in a secondary care environment. So how do you go out to the community? And I think this is where we have to work with the people who are out there already. There are amazing community urgent community response teams that can go out to patients and assess patients. These are usually very experienced nurses that can go out and work out whether a patient needs to go into a hospital or not. Oncology and cancer have never linked with these teams so that's again something we've got to start doing is linking with the teams that are already out there. I don't think as oncology ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 24:16 Mm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 24:22 services, we can say we're going to sort the whole lot out and we're going to own the whole lot. This is about us going out and saying, okay, it's not our comfort zone because it's not a secondary care facility, but actually what's out there? What's primary care are we doing? What are the urgent community response teams doing? Things like can you link your hotlines to the emergency community response teams, which I know greater, I'll get the word in a minute, Cheshire and Merseyside Cancer Alliance have already done. So they've managed to get their hotline that if a patient, say, is miles away from the cancer centre, they can get the emergency community response teams to go out, assess the patient and work out whether the patient can be managed at home or come in. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 24:51 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 25:04 But for the existing UCRs and for primary care, we've kept a bit of a boundary and I think it's our making as oncology a bit like it's very specialist, it's very complicated and it's only us that can do it. I think we've got to break that barrier down and say actually there are some general principles that anyone can do and you are safe seeing cancer patients. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 25:22 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 25:25 and we will support you to do that. But we've almost got to release that kind of control because we cannot provide the service we've provided for the past three or four decades where it's all going to the consultant oncologist who makes the decision. We've got to embrace all of these community initiatives, pull them together, but support them and teach them. And that's how I think we're going to end up being able to do neighbourhood. Patients can step up or step down onto virtual wards. So, you know, if the urgent community response goes out and says, I think this patient could have a PE, but they need a, they might need to have a CTPA, you can step that patient up onto an oncology virtual ward, get the CTPA done, ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 25:44 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 26:02 manage them whilst they are entirely at home with them only having to come in for a planned diagnostic of a CTPA. So these things can be done and have been done in pockets of excellence. So we've got to just share that knowledge of how we roll that out nationally. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 26:12 Mhm. And if you were building this ideal service, what would it look like? And feel free to say, look, it would look identical to your own because you've built your own. No, but. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 26:30 So, ours is being built, it's not been built. But, you know, I think very much the vision we've had in Greater Manchester and Cheshire and obviously working with the Christie, we've sort of put it into three main phases. So the first phase was to start to get ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 26:32 Yeah. Yeah. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 26:50 daily acute oncology consultant support for every acute hospital in Greater Manchester. There's 15 acute hospitals in GM. So we've been able to, by setting up a virtual acute oncology MDT, get the acute oncologist every day into those hospitals on iPads. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 27:08 And who's in this acute oncology MDT? WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 27:11 Yeah, so that is the Christie acute oncology consultants and it's the acute oncology nurses that are running this teams there. Sometimes we've had ITU consultants join us, medical aspect join us, A&E join us, depending on where the patient is, but it's very much coordinated by the AO CNS knowing where the patient is and who needs to talk to the consultant. ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 27:14 Mhm. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 27:33 So that was very much to try and expedite discharge, stop unnecessary investigations and get the patients out of the hospital or not even admit them. Then our second phase of work that we've done has been about ambulation. So this has really been working with our medical aspects to say, and again, 15 medical aspects across the Greater Manchester, will you ambulate? these common 5 conditions that the Society of Acute Medicine and UK Acute Oncology Society have endorsed. So that's work in progress at the moment, but we've got an implementation plan for that. And then phase three is acute oncology at home. So how do you do it? And I think how we're looking to do that is to link with some of our community providers. So that's linking with our urgent community response teams. It's also linking with our hospices. So our hospices are very be able and willing to do some things like, I call them emergency, emergency infusional work. You know, it's your blood transfusions, your magnesiums, your sodiums, all the stuff that doesn't need to come into a hospital but can be very protocolized. Talk to your hospices because they may have ability and desire to collaborate with you and to do some of that work for you. So it's moving stuff ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST) 28:28 Mhm. Okay. WILSON, Caroline (THE CHRISTIE NHS FOUNDATION TRUST) 28:41 closer to the patient's home. The ultimate thing that we want to do as part of our neighbourhood oncology is to actually look after the patients in their own home. Now, that's probably going to be teams of band 4s doing bloods, you know, band 6 or band 6 is assessing the patient, 7s coordinating, and then your senior decision makings decision makers being your eights, band A, A, CNS with that consultant oversight if they're on virtual wards that has to be every day. So it's probably going to be a nurse led service that's in the community, very much like your AO services already are in secondary care with that consultant level acute oncologist who's supporting for those complicated decisions and overseeing safety.