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Episode 4 Setting up a Pleural Service: Lessons from the Front Line
255 Plays27 days ago
What does it really take to set up a successful pleural service? In this episode of the UKPS Podcast, we sit down with Dr. Helen Roberts and Dr. Raja Reddy, two experienced pleural consultants to explore the practical, clinical, and organisational realities of developing a pleural service from the ground up. From defining the scope of a service and securing institutional support, to workforce planning, governance, training, and sustainability, our guests share hard-won insights and real-world lessons.
Packed with practical advice and honest reflections, this episode is ideal for anyone considering developing or refining a pleural service, and for those wanting advice on building a service that is safe, effective, and future-proof.
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Transcript
Introduction and Guest Welcome
00:00:00
Speaker
Hello everyone. Welcome to the fourth episode of the UKPS podcast. My name is Marlsika. I'm one of the research fellows at Oxford and I'm joined by my colleague, Beanesh.
00:00:11
Speaker
Hello, hi, I'm Beanish, I'm one of the ex-fellows from Oxford and we're delighted today to have two of our lovely speakers who Melvika has going
Challenges in Pleural Services Setup
00:00:22
Speaker
to introduce further. Thank you, Beanish. The focus of this episode is setting up a plural service which a lot of us might consider as a challenging experience, particularly as you have to balance patient safety, training, governance.
00:00:36
Speaker
alongside the realities of limited time and resources. And so our guests today are Helen Roberts and Dr. Raja Reddy, who are two consultants in the plural world who have established plural services at their respective hospitals in different settings and we'll be discussing with them about their experiences. So thank you so much, Helen and Raja, for being on this episode. And would you like to introduce yourselves, please? I'm a consultant at the Kettering General Hospital and I've been here for a good 18 years. I'm Helen Roberts and I'm a respiratory physician at Sherwood Forage Hospitals. And then before that, I was at a different trust for 13 years. So I've been involved in setting up two separate plural services with very different trusts.
00:01:20
Speaker
Brilliant. Thank you so much. And I think your varied experiences in setting up plural services will be quite useful for our listeners. So I think I'm just going to start off with the first question and I'll start with Helen, if that's
Personal Experiences in Service Development
00:01:32
Speaker
okay. So I think when you first started to build the plural service, what was the problem that you were trying to fix? What was the issue?
00:01:41
Speaker
So I think most of us are probably in a similar situation where our pleural service and our cancer services will often run together. And I think we all know what it's like to be in a really busy cancer clinic and then you pick up a new patient to find they've got, you know, large pleural effusion. And suddenly you're trying to deal with that in the middle of a overbooked cancer clinic and you don't really have the right place or the right sort of mindset, I suppose, to deal with that. So what we were trying to do with...
00:02:07
Speaker
separate those two things out so that they do work together. But actually, if your primary problem is plural, then you come separately to a plural service. But we offer, you know, appointments in the same timeframe that if you went to a 208 cancer service, really, that's what we were trying to get away from to provide a better service for the patients, but also for us really make it a bit more controlled and organized. Absolutely. I think with the two overlapping, cancer and plural, with such an overlap.
00:02:35
Speaker
Managing patients, making sure that they've got a streamlined pathway is is challenging. And I imagine that a lot of people do come across this in their respective services as well. And what about you, Raja? Did you have a similar situation? Was it slightly different at your hospital?
Resource Acquisition and Staffing Needs
00:02:51
Speaker
Yeah, it was completely different at our hospital. When I joined here in 2007, I think, the entire respiratory service had completely imploded. All the previous consultants had left. There was nobody at all.
00:03:07
Speaker
So ah for me, it was a challenge as well as an opportunity. It was just trying to get the respiratory service up and running and whilst instead doing it, try and find ways of delivering the service ah as cost effectively as possible.
00:03:24
Speaker
Absolutely. there but There was nothing to start with. The first help I got was really help with the purchase of an ultrasound machine. And kick-started the whole process. So things moved on from there. We were initially using it to improve patient safety.
00:03:41
Speaker
there there was I wouldn't say there was anything called a plural service at that time. And the concepts of it also were pretty rudimentary. So it took us quite a while.
00:03:54
Speaker
to get the the entire service correct, the respiratory service itself. And then we moved on with that doing pleural effusions on a sort of a outpatient pathway and then started the pneumothorax service. All the while we Still did not have any support at all in terms of plural nurses or anything like that. We just iterated on the move, did whatever was necessary. and it took us a good seven years or eight years before we had our first plural nurse to support us.
00:04:29
Speaker
so um Wow, okay. so that sounds quite varied then to what Helen said. So you started from the ground up. and Helen's experience was, yes, certainly a fresh floral service, but drawn out from the lung cancer services. So quite interesting, different experiences. And I guess that sort of brings us to our next question. What were the absolute essentials that you needed to get the service off the ground? And what aspects did you think were essential, but actually later on you found out that they weren't?
00:04:59
Speaker
So I think like all things, staff are the priority really when you're thinking it through how are you going to deliver your service. Actually, we found that if you look at how many plural patients were in the cancer service, it's a lot. So actually, if you were then going to move them out of the cancer service to a sort of parallel stream, then actually we could repurpose some of the cancer PAs for that process. So we did have extra people, but Some of it was just about rearranging the services that we had already. So staff was really important. We then had a business case for plural nurses.
00:05:32
Speaker
And again, it was important to decide what do you want from the plural nurse service because some centres have a plural nurse whereby they do a lot of patient communication and organisation and support, but they don't do procedures themselves. But we decided to go for the other option, which was a plural nurse who would do those things, but also would be fully independent at plural procedures. You've got to factor in how are you training that person and then how's the consultant time coming to do that. And then, of course, when that person is independent, they're going to need some sort of healthcare assistant maybe to help them when they're doing independent plural procedures and things. So staff was a big thing. We probably didn't apply for as many staff as we should have done in our business cases. that You don't really realise until afterwards that you're going to need...
00:06:17
Speaker
more people than you think. And then really it was about how were we going to run the clinics? How often are they going to be? And actually we found we did it once a week to start with and then we rapidly increased to twice a week. So now we have two clinics which work as a sort of clinic slots to start with for the first hour and a half and then procedure slots after that. And then there's a separate procedure list as well. So we have three sessions a week basically. We can do stuff ad hoc but that's basically it.
00:06:44
Speaker
And then the other things that were really important is where are you going to do it and how are you going to control that space? And then the other things that came up as we were going along really related to training, because whilst you're training a plural nurse you do need to make sure that your registrars still have training opportunities and capacity. And we worked quite hard to make sure that those opportunities were shared so that everybody got a good experience really.
00:07:08
Speaker
And then maybe something that we hadn't thought quite so much, we set the service up and then I realised, say, the oncologists weren't particularly using it. So ED were using it, but oncology weren't, I think, just because they didn't really know about it. A big piece of work do we did was about communication. And so we made it so that referrals to the pluralservice are all digital. They're all done through a computer system. And oncology, yeah everybody at ED has access to that. And that turned out to be really important because once you let that out there, everybody uses your service. Whereas when you first set it up, nobody much was realised it was there.
00:07:38
Speaker
So I'd say those were the biggest things for us, really. Great. Okay. I'm going to ask Raja a question about that. It's very fascinating that your service is very ambulatory. I would say it's quite revolutionary in some ways because you have had that for many years.
00:07:53
Speaker
that you manage you manage patients in an ambulatory fashion and which even predates the trials that have actually supported that. So how did you get about setting that up with that vision 18 years ago or did it develop over time?
00:08:09
Speaker
And also how it's it could be sometimes one person's vision, but then what's the ethos for you to carry that on among your other colleagues that they all have following the same method or are there different ways of managing patients within your department?
Innovative Approaches and Overcoming Skepticism
00:08:26
Speaker
We just took on whatever came our way really. There was nothing so we had a clean slate which in a way was a blessing. I wasn't following anybody and also because there was nothing people looked up to you to deliver and then eventually because there was nothing i became the lead and once I became the lead I was leading the way in a way I could do things much more easily.
00:08:53
Speaker
i wouldn't say whatever I wanted, but it was easy to convince people to see the way I do, which is always trying to deliver services in the most cost-effective way. And that's why this business of ambulatory management came about.
00:09:10
Speaker
there There was nothing. So we, hence we iterated, as I said, On the way, we just took on any challenges which were thrown at us and found solutions, luckily, which worked for us. And of course, it's ah not that I was developing everything in a silo.
00:09:30
Speaker
we also had a wonderful floral service running within the country, floral services developing. So it's interacting with people, finding the challenges and of course, finding the solutions to it, to deliver. So I helped along the way by myself being the lead and then the clinical director. So I could convince a lot of people easily.
00:09:55
Speaker
So whatever I did wasn't the thing to do in those days. A lot of trainees or my consultants who trained elsewhere weren't tuned to what I was doing.
00:10:07
Speaker
But it was easy to convince them by supporting them. So if they had a difficult patient, I would step in, I would help them so they could see the potential in ah what I was doing. That's how we built up the services.
00:10:23
Speaker
And we we didn't really wait for others to come and help us. We did it and then asked for help if we needed it. in a way we didn't ever have to develop a service which we thought was wasteful or excessive or things like that so i was very much improvising all the time to keep up with the times or to keep up with any new developments for example a conservative management of pneumothorax wasn't something we thought about and then suddenly this paper appeared in 2020 i think so and then we were able to amalgamate it into our existing ambulatory pathways.
00:11:05
Speaker
Great. And just a follow-up question from that, Rajah, if that's all right, is that ambulatory service requires a lot of manpower as well. And yes, it could be cost-effective in a way that it's you're saving beds.
00:11:19
Speaker
You probably might not be doing interventions or sometimes actually do intervention and send them home. Yes. then you might do just watching them for a day. And then people's time, number of phone calls they might be taking, which kind of gets unnoticed if if it compared to somebody being admitted and the work gets dispersed, multiple people are looking after the same patients. So how did you get about that nervousness, if I would say, could be that...
00:11:49
Speaker
these patients are out and about in the community. du Did you need more people to support that service to run or were you doing more than you should be? How did that
Communication and Flexibility in Service Setup
00:12:00
Speaker
work? So initially, because these were ah new services, nobody would believe you if you just say, yeah, I will do this ambulatory pneumothorax service, especially when nothing of that nature has been done elsewhere and published. So you're always met with the skepticism from within your own team. That's natural.
00:12:22
Speaker
They always tend to believe something else published somewhere rather than you who is delivering the service. As I said, I was there for most days. I was okay. I was doing more than I should, but it didn't affect me in that in that way, in the sense I was enjoying it.
00:12:42
Speaker
So I didn't feel as if it was work for me. I absorbed all the challenges and any difficulties we faced. Yes. But then once the services were up and running, was easy for other people to see how effective it is. And I got initially the support of one plural nurse and then for a hospital of our size. At that time, it was unheard of to have two plural nurses. So we did get support eventually. Along the way, we accumulated my colleagues and registrants who all were helpful and we built an excellent team.
00:13:18
Speaker
eventually it's the team which matters because you can't always be there so that way I would say do ah get a good and excellent team around you yes thank you that's really helpful thanks Rajah so I guess that brings me to my next question and I'll ask you this Helen what do you think was the biggest barrier when you were setting up the service if you had to name one thing and how did you get around it So I think the two services that I've been involved with were very different. So for the first one, the location was our biggest barrier. And I always remember one of my colleagues who was involved in it spent ages sorting out. So we found a location which seemed to be perfect, was on the ground floor, easy to get to for patients, and it was adjacent to the ward. So it was all, we thought that was a good location. And he spent an awful long time sorting that out.
00:14:06
Speaker
got the Plural Clinic up and running, was very pleased with it, and then came in one morning to discover that all the spaces for the Plural patients had been converted to inpatient beds overnight when when it was busy. So for us in that location, space was an issue. So it seemed like a good idea, but I think if you're choosing a location, you really need to find one where it can't be turned into winter beds when you're not looking. For this service, we went in that position, but just getting the oncologist to use it was our biggest challenge, I think, just because they had a bit of a habit of seeing someone in clinic with an effusion and then just admitting them and asking radiology to put in a
00:14:44
Speaker
a small pigtail drain, which is obviously not what we would want, particularly if the patient wants neonies pleurodesis or something like that. So getting them to use it was probably our biggest challenge. But actually, it's again, as Rajah says, it's it's about communication and talking to colleagues. And eventually they got it. And once some of them got it, it spread. And now they all like just refer everything, which is fine. Because we'll see them the next day. And they don't need admitting. That's the thing. But I think the digital system helped with that. Because if they know they can just put a referral on our system, which is eyes, then it's easy. They don't have to ring anyone up or otherwise it's easier for them to just say, admit the patient from clinic. So, yeah it does depend a bit on your trust, I think. But yeah, absolutely.
00:15:25
Speaker
Thank you, Helen. we And what about you, Rajal? I would say it's overcoming this skepticism and convincing people that we could do it and deliver and getting the right support for it.
00:15:38
Speaker
Yes. But once we've shown it, people always tended to believe it once it's been done. And there was support to after that. But it's the convincing part of it for any new service you're setting up.
00:15:52
Speaker
great Lovely conversation going on. So I'm going to ask Helen a question that if I am starting as a new rural consultant, I'm nowhere near, but let's imagine I am. So if I come to you and ask you that this ah hospital that doesn't have a rural service or has a very basic level service that I don't think we are delivering very well and we can improve,
00:16:17
Speaker
How would you guide me through as a mentor that these are the things you need to do from to begin with and how to follow up on things?
Advice for New Consultants
00:16:28
Speaker
So I think I'd say it was always a quite a big job, isn't it So I think the first thing is to say not to expect everything to be instant because it is going to take time to build up a proper plural service. But probably wherever you are has got a cancer service and they probably have got plural patients. So in a way, they've probably already got...
00:16:44
Speaker
some of what you need. So I think if I was doing that, I'd be looking at how many plural patients where the predominant problem is plural. So the way we split ours is if when when they have their, either they've come to A&E or they come for a two-week rate scan, if they if they're going to need fluid management, they come as a two-week rate to the plural service. If it's just a little effusion and the main problem is lung cancer or whatever, they'll go to the cancer service. So that's how we divide them. But If you work out how many of those you've already got in your cancer service, it will be a lot. And therefore, you can when you're writing a business case or making your argument for splitting them, you can use that because actually you might not meet with any extra PAs. It might just be partly reorganization.
00:17:28
Speaker
But then really once you've got that sorted, it's really, as we were saying before, about where are you going to do your clinics? How is that going to work? So we have a one-stop shop so that the patient comes to a conventional clinic appointment and then we have those slots. And then following that, we have procedure time. So if a patient comes that morning and then needs something doing, we'll just do it afterwards if that's suitable for them.
00:17:54
Speaker
Obviously, some of them would be on anticoagulants or whatever. But if that's the case, our plural nurse tends to try and ring them before so that they don't have then a wasted trip and a second visit. So I think that's you're going to staff it.
00:18:06
Speaker
Where is it going to be? How often are you going to run it? how are you going to train people? Because obviously success in planning is really important and we'll all retire and then it'll be left to whoever's coming after us. You know, how you really need to provide good training and the better the training is, the more people want to come and therefore better your service runs really. And then the other question is about how do you fund your plural nurse? And that depends a bit um on the trust and the area you're in, but you could explore looking at reduced hospital admissions as a way to argue business case. We used Cancer Alliance funding There was a setup of a day case unit and that we could write that into the business case. So there are a variety of ways, depending on your trust, you could fund it.
00:18:46
Speaker
But those are the sort of big things, I think. And then as I say, like, how are you going to get people to use this service, particularly A&E? That's where we went first, because obviously the pneumothoraces, they need to do it and they do it brilliantly now. They love it because they just see the patient, send them home and put the referral on the system and say for them, that's great.
00:19:04
Speaker
But yeah, I'd say those are the main things really. But it just obviously takes time. And just to follow up on that, did you then gather some more data when you started off with your baby steps?
00:19:17
Speaker
Like, okay, this is what we're doing. And did you have to show cost effectiveness and to continue to improvise it and add more staff? So what we did was look at admissions, the number of admissions. So obviously we pretty much stopped admitting people with pleural effusions and pneumothoraces unless there was some other reason for them to be in hospital. So you could look at saved bed days or reduced length of stay.
00:19:40
Speaker
We looked at time to procedure and that kind of thing, because obviously if people are very breathless and they're waiting quite a long time to have whatever procedure is, they might come in or they might have to have more than one procedure. So we looked at that kind of thing, know, trying to reduce it to the smallest numbers of procedures possible and therefore being as cost effective as possible so yeah we audited all that stuff from the beginning because we only had one clinic to begin with we just had one and then we audited that and then used that really to drive getting a second clinic plural nurse and ah and then separate procedure lists
00:20:13
Speaker
And Raja, if I ask you that question, I'm coming to you as a new consultant setting up a service. What do you think the advice you would give me and how to follow up on that?
00:20:24
Speaker
Looking back, it's it's a lot easier nowadays because there's a lot of evidence already published available in terms of the cost effectiveness of Various pathways, including the early fusions and the best practice tariff which goes with it. It's much more easier to get a business case going nowadays. I think speak to your colleagues who have already set up the surveys and there'll be a lot of help for you in terms of paperwork and all that from people who have already done it.
00:20:57
Speaker
But more importantly, I would say, whenever you're setting up a service, you have to be prepared to be flexible, to be patient, and also you have to be prepared to be hands-on, especially when there are procedures to be done.
00:21:12
Speaker
ah Occasionally there will be days when there will be nobody to do it. And if you look at me, I still do chest pains, I still do little aspirations. and So one has to be prepared to do hard work as well.
00:21:24
Speaker
Yes. There are lots of pathways which you can fall back on and implement. Of course, you always have to tailor them to your own service and get the cases going to have a plural nurse to help you with the savings you you will make with a new service like a plural service.
00:21:46
Speaker
Thank you. And I guess that's all been very helpful. And ah i suppose just ah in terms of closing thoughts, when you reflect on your respective journeys on setting up plural services at your centers, is there anything that you would do differently if you had that in in hindsight?
00:22:06
Speaker
I think for me, as Rajah says, it's become a lot easier. So the second time around, it's a really supportive trust and we've got a huge day case unit. We've got our own procedure room and we do everything and all that kind of thing. But to begin with, it was all quite new. I think I started in 2009, so a couple of years probably after Rajah. And to get an ultrasound machine, we had to get charity funding and it took ages to actually get anybody to be engaged at all. So I think it is easier now, but I think if I had to choose one thing that I'd do differently, it would definitely be would be the location for the original service. Once you've started something, it's very hard to move it.
00:22:42
Speaker
It's easier if you, because otherwise everyone gets used to the fact that the plural service is pushed into a cupboard that isn't really suitable and why would you want to move? so I think if you can push for a good location, I think I'd probably go for that and everything else can come along with it.
00:22:58
Speaker
but So as far as i I'm concerned, I would echo Helen in a way. Initially, we were all relying on other facilities, other services or other people's territory to run the service. Like we were using the medical same-day emergency care to help with finding space to run the service and also relying on the nurses from within that service to help us. not bad but if i had the facilities maybe i could have done a lot better a lot earlier in terms of our own ambulatory care facilities right now we have managed to create our own space we call it the respiratory ambulatory care unit to run the whole of our plural service through that unit and much more we have all the virtual boards running through it because it's an ambulatory care facility if somebody
00:23:54
Speaker
any one of your patients, for whatever disease, plural or otherwise, is in the community, you ought to have some space for them to come back to should there be a problem.
Future of Pleural Services
00:24:05
Speaker
So that's something we didn't have initially, but that is something I would recommend if it is possible, because that gives you much more control of your own destiny. That's very helpful. And the final question I wanted to ask was, where do you see the future is going with regards to the plural services? Because You've come all the way from everything inpatient to a hybrid model in most hospitals, some ambulatory stuff, some inpatient, some services like yourselves, Rajah, where everything is more or less ambulatory. There is a shift now to try to move things virtually or home-based reviews.
00:24:48
Speaker
That's also coming in definitely acute medicine and is... running the show in that. And we, of course, have to do procedures more or less on patients. So fitting that in is probably going to be challenging. But do you have any vision of what the future is going to bring with regards to plural services?
00:25:08
Speaker
So i think really, if you're breathless, you need something doing about it, doesn't it? And that's the quality standard is going to be that i can't remember if we said five days or something from the decision being made. But I think if we can aim for that, it's so many times it's difficult, isn't it? Perhaps somebody uses their endoscopy suite or something and they have to wait two weeks to be able to get a slot to be able to do their procedure whatever. So I think independent services where people can have treatment.
00:25:32
Speaker
you know as soon as possible because being breathless is dreadful and that they therefore get the best care but also in an ambulatory way as possible because if you leave them the chances are they'll come in and that's not good for anyone is it so I think a mainly ambulatory system obviously there are some people you need to come in we've done some community things obviously with IPCs and things there's already a process in place for community nursing and people going into people at home it really does depend a bit on your patient cohort we've got quite a lot of patients who don't particularly like people coming to the house they don't like waiting for people to come and they would much rather come to a a service that's quick so they can just come up here maybe some of them come here to be drained because they don't like being drained at home so they'll just turn up have it done go home and they're happy with that so I think it's just really if we can have a prompt service but one that's tailored to patient needs because not everybody's going to want the same thing really and Raja what do you think where is your service going to go now
00:26:28
Speaker
I always wonder that myself, we develop a service and then I think, what next? If I don't have anything next, I'm almost lost. So luckily, as we develop, because I'm hands-on, something or the other always happened where we found a new way of doing something.
00:26:46
Speaker
Yes. To be frank, I don't know myself. what's What's it going to be next? But what I would say definitely is, looking at the whole the structure of the NHS and where it is running, you will see more virtual wards.
Seven-Day Service Feasibility
00:27:01
Speaker
You will see more ambulatory pathways.
00:27:04
Speaker
And more importantly, you will probably be also looking at on-demand services. Okay, if something needs to be done, are you able to deliver that on the same day?
00:27:16
Speaker
Things like that. Yeah, think that's where we are moving. And if I have to ah look at a specific condition within plural diseases, I would say with the pneumothorax service, you know, what I'm foreseeing, I would say, whether it will happen or not, I don't know, is some sort of a conservative ambulatory model where...
00:27:39
Speaker
You deal with the patients on conservative pathway, the pneumothorax, and then, of course, a portion of them will always require drainage. Can you then manage them on the ambulatory pathway so that they don't really have to touch the hospital at all throughout their entire pathway? As an inpatient, they don't have to be in hospital.
00:28:02
Speaker
That's what I'm working on currently, but I would definitely say on-demand service is something ah which would be great for the future. Yes. I suppose thinking in terms of procedures and the fact that plural medicine is procedure-heavy sort of specialty.
00:28:19
Speaker
So if we take away plural procedures from the general medical team, do you think we can deliver a plural service which is a seven-day plural service? Shall we start with Helen? So you definitely can do that. We don't have, GAM don't deal with any pleural disease for us now. And so the way that works is obviously for pleural effusions, they mainly should be outpatients anyway, unless there's some social reason or some reason they can't be at home, then if they come to ED, we will see them and they go home and we do everything. we might aspirate them today or might aspirate them next day, whatever. We'll sort it out with the patient. So we don't really have GIM um teams doing anything from a pleural perspective, And I think in the in end, that's going to be forced upon us because the truth is they don't have that level of training anyway now. It's become so sub-specialized. So do you need out of hours pleural effusion? Probably you don't really do. Pneumothorax, obviously that's different. For the ones who need intervention, ED will do it.
00:29:16
Speaker
So, GIM and acute med don't get involved at all from our point of view, but we do have a respiratory on-call service and of course not everybody has that. It would depend a bit on how you the rest of your respiratory on-call service is set up, but you definitely can do it. That's what we have.
00:29:33
Speaker
What about you, Raju? So, yeah, for a small hospital like ours, we are a big respiratory team, so we get by, but I do get it. A lot of hospitals don't have as many respiratory physicians as we do. If you look at it from their perspective, it is difficult.
00:29:51
Speaker
But I think it is still deliverable in terms of if you have a good plural nurse who you have trained to do procedures ah like ours do, then it's possible for one of the plural nurses to work over the weekend. So you can overlap. They work over the weekend and then you work during the weekdays or vice versa. So I think if you can train your plural nurses well, i think that it is possible that ah you could deliver some sort of interventional plural service seven days a week.
00:30:27
Speaker
Great. Thank you very much. I think this was an excellent, and insightful discussion and about actually the practical aspects of going plural, basically, because we talk a lot about things, lot about research, but actually how does the work happen on the ground floor?
Conclusion and Appreciation
00:30:43
Speaker
This has been amazing and really coming from the people who have actually done this in the it's part of their services is personal and special because this is a guidance for all people who are currently have a service that they want to improvise or revamp or also for people who are starting new or are going to start in the next couple of years to what should be the starting points and take inspiration from yourself Helen and Raja I can understand and I can read between the lines that how much work would have gone into just trying to
00:31:18
Speaker
establish these services and the ultimate goal of all of us is to serve our patients better and I could really hear that emotion through your discussion so thank you very much for being exceptional in your careers and being trailblazers in that way and thank you very much for giving us time today to talk about your experiences and your journey to being setting an example for upcoming people and I'm sure you wouldn't mind if people after listening to your excellent podcast and I get in touch for some more nuanced questions or some personal advice, if would that be, and guide all the future generation of plural consultants. So thank you very much for your time today.