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Reforming Cancer MDT Meetings Across Greater Manchester

Multidisciplinary Team Meetings (MDTMs) are a well-established aspect of cancer care and have been regarded as gold standard practice since the Calman-Hine report of 1995 and the NHS National Cancer Plan in 2000. Over the past 25 years, there has been little change to the format of MDTMs despite significant changes in cancer care. A need for significant change was supported by Cancer Research UK in 2017 and confirmed by NHS Improvement in 2020.

It is agreed that by improving communication and documentation between team members and adopting a more streamlined approach to MDTMs, there is significant potential to release clinician time, which could then be repurposed elsewhere in patient care.

To support this, an MDT Reform Programme of work has been developed following an 18 month MDT Reform Project with a dedicated project group and Clinical Lead. This has led to the development of agreed, co-produced Greater Manchester MDTM Standards detailing what principles should be central to Cancer MDT working across the Region, with examples of good practice, to encourage shared, peer-peer learning, and continued reform.

The 10 principles within the standards

There should be a standardised, single point of entry to an MDTM

A minimum dataset is required for safe MDTM discussion and decision making. The use of a standardised pro-forma that collates this information prior to the meeting should be mandatory so that safe discussion can occur even without the presence of the referring clinician. MDT Coordinators should be empowered to be able to insist on the use of the agreed pro-forma prior to listing a patient on the MDT agenda.

The minimum dataset will vary dependent on tumour site however most will need to include patient demographics, WHO co-morbidity status and the Rockwood frailty score. The clinical question for the MDT should be clear and any imaging or pathology specimen numbers and dates should be outlined. Any individual holistic needs identified that will impact on treatment choices should be highlighted on the pro-forma to inform MDT discussion.

MUO – CUP Referral Proforma

Lung Service – MDT Referral Form

The patient impact statement should be utilised to inform MDT discussions where possible.

Utilisation of the patient impact statement

The patient impact statement was developed as part of the gynaecology pathway MDT reform work and co-produced with service users. This is being rolled out across all pathways and the statement supports the patient in being part of their care planning process, reflecting what is important to them to bring their voice into the MDT.

Patient Impact Statement template

Case Study – please listen to me

Safe, clinically protocoled pathways for defined patient groups should be agreed at a national/regional level.

Standards of care (SoC) can be used within tumour sites with well-established pre-defined treatment pathways, where there is clear consensus and where a patient may not require a full discussion. SoC can be used in a pre-triage meeting where effective care planning can take place without the needs for discussion within the main MDT.

It is a point in the pathway of patient management where there is recognised national or regional guideline on the intervention(s) that should be made available to the patient and should focus on those points in the pathway where there is clear clinical consensus on the treatment or care that a patient should receive.

Breast

Standard Care Plan – Early Breast Cancer

Standard Care Plan -Oncotype V1

Standard Care Plan – pre-op HER2 positive breast cancer

Lung

Lung Standards of Care

OG

Standards of care for barretts, LGD and IND

Pre-Triage meetings support MDT reform to effectively streamline MDT meetings by way of way of reducing the number of cases requiring formal MDT discussion. A single or a small focussed group of suitable clinicians may meet together with an MDT co-ordinator in advance of the MDT to determine those cases that are to be listed for formal discussion, those who are not yet ready for formal discussion and those cases suitable for management by protocolisation using SoC pathways.

Outcomes from a pre-MDT triage meeting should be clearly and efficiently communicated to the whole MDT team and any actions should have a responsible healthcare professional identified and documented.

Breast Pathway

OG Pathway

  • The person responsible for each MDT action and the person responsible for communicating the outcome to each individual patient should be highlighted in the MDT outcomes.
  • Communication with patients may be virtual (telephone or video consultations) or face to face. Where possible patients should be offered the choice of consultation type prior to the MDT, which can be recorded in the patient impact statement.
  • Communication of the MDT management plan to the patient should be achieved within 2 working days where possible. Teams should consider how working practices may be altered to ensure patients are informed as soon as possible, in the way in which the patient prefers. Teams should carefully consider whether the person delivering the news has to be a specific clinician or healthcare professional.
  • Please consider informing the patient’s GP regarding outcomes of the MDT discussion.

Continuous improvement through the audit of Documented Treatment Plan Outcomes compared to Actual Patient Outcomes

MDT decisions do not always match the outcome of the patient. The concordance of the two outcomes is a measure of the accuracy of the information provided to the MDT and the quality of the discussion and the team-working skills. Teams should ensure that there is evidence of an annual “snap-shot” audit of MDT management outcomes compared to the actual outcomes of the patient discussed. Any discrepancy may inform team learning and reflection with a focus on reviewing any mortalities and specific complex cases. Any new national or regional guidelines should be highlighted to the team and any local guidance updated accordingly to support this auditing process.

CUP Audit Template

CUP MDT Data Collection Template (Bolton)

Key Service Activity (WWL)

The national requirement is now for individual scheduled treatment planning MDTMs to be quorate on 95% or more occasions. There is no longer a requirement for a minimum attendance by individual members6. This gives teams more flexibility with the number of clinicians who need to be present at each meeting and means that clinical expertise can be streamlined and utilised in other parts of patient care. This should enable each individual MDT to re-organise their clinical time to develop the changes outlined above. Core membership is different for each tumour group but is outlined and regularly updated in UK cancer guidance.

Communication of outcomes of the MDT discussion to the referring clinician should be performed within one working day

The MDT coordinator should ensure outcomes from pre-MDT triage and MDT discussions are distributed to all referring clinicians within 1 working day of the main MDT meeting.

GM Cancer recognises that there is an opportunity to offer a training scheme for all MDT chairs to improve and hone their chairing skills. There is a regional aim to work towards a standardised job description for all MDTM chairs.

Remote MDTMs can be a useful tool in modern practice but can also lead to some team members contributing to discussion less often than they would if the meeting were face to face. A “cameras on” policy can be helpful to manage these complexities and MDT chair training should include some specific approaches to these unique remote meeting challenges.

The importance of effective leadership and chairing cannot be over-estimated. Chairs should ensure they manage discussions to ensure all team members are able to contribute to treatment decisions and that the holistic needs of the patient are considered.

Where possible the MDT Chair should guide discussions to highlight any relevant clinical trials to offer to the patient.

Other team members may benefit from opportunities for peer-peer learning on how to present cases effectively and succinctly to allow a fully informed yet efficient MDTM discussion. Such learning should be encouraged and facilitated by Trusts.

Teams should ensure quarterly reflection on any mortalities as well as any learning from specific complex cases

Any new national or regional guidelines should be highlighted to the team and any local guidance updated accordingly

MDTs should ensure an audit of outcomes a minimum of twice a year for patients on SoC pathways and highlight where patients have been managed inappropriately on one of these pathways and investigate how this can be avoided in the future.

GM MDT Reform Standards

Take a look at the GM MDT Reform Standards

GM MDT Reform Toolkit

View our new MDT Reform Toolkit

Keeping the patient at the heart of MDT reform

During the project we worked collaboratively with patient representatives to co-produce patient resources.