Multi-Disciplinary Team Meeting Reforms

Background During 2017, the 12 Chairs of the Cancer Network Groups studied the recommendations from the Cancer Research UK MDT Effectiveness Report, and identified areas where changes could be implemented, including the following: Development of treatment protocols Review of MDT attendance Improvement of incoming information/real time data collection MDT Mortality and Morbidity reviews. In August 2017, Professor Martin Gore was appointed by the National Cancer Transformation Board to reform MDTM working arrangements across the UK

Response The SSG Chairs decided to hold a meeting of the SWAG Cancer Clinical Leads to define a loco-regional approach to MDT reforms prior to meeting with Professor Gore and his team All MDT Leads were invited and representatives from each cancer site attended the meeting

Guest Speaker: Cognitive Scientist, Tayana Soukup Acencao Improving teamwork can increase meeting quality Teamwork can be assessed and improved using validated tools Training is needed to use the tools Improvements identified can be made via audit and feedback cycles

Inaugural meeting of the SWAG Cancer Clinical Leads, Monday 16th July 2018 Guest Speaker: Cognitive Scientist, Tayana Soukup Acencao Cognitive fatigue after 1 hour/discussion of >20 patients reduces the quality of decision making. The addition of a 10 minute break has been shown to balance the quality of decision making and reduce the length of the overall meeting: SWAG MDT Priority Recommendation

SWAG MDT Priority Recommendations To arrange visits to alternative MDTs to compare different styles Development of online MDT referral proformas (starting with Breast and CRC) to improve quality of information / allow for triage of cases Skin referral proforma already designed

SWAG MDT additional recommendations Improvement of video conferencing facilities (specifically the network systems) Administrative support for tracking results / a regional digital tracker for use across the region (it was noted that Gloucestershire Hospitals do not have the same system as the other SWAG Trusts) Protected MDT planning time to stratify discussions so that radiology and pathology colleagues can attend a specific slot Training for MDT Coordinators to assist with stratifying the MDT meeting

SWAG MDT additional recommendations Design a process by which the patient pathway can be progressed outside the MDT with decisions documented to ensure an audit trail is fed back to the MDT Provide GP advice and guidance on making appropriate referrals Training to use the MDT assessment tools Specialist radiology and pathology reviews of agreed cases outside the MDT meeting Encourage referring hospitals to start diagnostic processes where appropriate Reconfigure room space.

Next Steps Professor Gore’s team has invited MDTs to join an MDT streamlining pilot to develop predetermined standards of care. SWAG Breast and CRC MDTs are participating in the pilot SWAG Cancer Clinical Leads are to implement recommendations from the meeting. Progress will be discussed at the next meeting, to be held in 12 months’ time MDT Assessment Tool Training Days: 19th and 26th June 2019.

British Association of Dermatology Response The British Association of Dermatologists (BAD) facilitated a multi-stakeholder workshop to discuss and propose recommendations for changes to the structure and function of Skin Cancer Multidisciplinary Teams (MDT) and Multidisciplinary Team Meetings (MDTM). This work has been supported by Professor M. Gore and Professor C. Harrison (National Cancer Director, NHS England (NHSE)) and our recommendation document produced as a result of the workshop will be passed to them for consideration during the reforms.

Key Messages MDTs remain a valuable resource but: Need to be reformed to improve productivity while maintaining value Must not create delays in management when protocols are straightforward Should be better focussed to discuss appropriate cases. MDT should review cases, agree and document management pathways to reduce the requirement for extended discussion of routine cases that can be treated as per protocol. Appropriate cases should still be listed and registered without exclusion. The MDTM fulfils an additional role as a source of support, education and management updates for the clinicians and trainees in a constantly and rapidly changing area.

Who Should Make Up the Skin MDT? Recommendations: Formalised job descriptions should be developed setting out the roles and responsibilities for the MDT Chairs and MDT Co-ordinator with educational requirements. Consensus agreement that Cancer units still need a LSMDT but with a streamlined membership which is physically present at meetings. Trials updates would be helpful for core members to discuss at MDT meetings.

The Case Mix Recommendations: Referral of cases for discussion should be via a proforma that is structured to capture all of the required information about the patient’s performance status, co-morbidity, preferences, Holistic Needs Assessment as well as essential information relating to the tumour and suitability for trials Adequate pre-MDT preparation time is required to structure the meeting and differentiate complex from straightforward cases. Each MDT should consider formalised management protocols for routine cases that can be managed on a treatment pathway without the need for formal discussion by the full MDT. Standardised information about the patient and questions being asked of the MDT on the agenda.

Recommendations continued Apart from triaging cases for protocolised management, MDT planning meetings should provide the opportunity to structure the agenda so that more time is set aside for complex cases, and to ensure that the right information (about the patient and the tumour) is available for the meeting. Level 3 Care Skin Cancer (see Appendix 1) referrals do not need to be discussed by the MDT. These patients should be seen and treated by the core consultant member of the MDT in line with local network guidelines Level 4 Care Skin Cancer Cases require mandatory case review by the LSMDT, however cases should be ordered in priority of their complexity with less complex cases listed with a treatment pathway, for ratification by the MDT Clinical trial recruitment is enhanced by the treating clinician being aware of available trials. The MDT discussion should be used as a checkpoint for ensuring that patients are considered, if eligible for a trial, and are supported to make an informed choice about their involvement. 

The ideal time, frequency and resources for MDT meetings Recommendations: The existing recommendations on MDT frequency is supported. National requirements for individual minimum attendance should be reviewed and amended to reflect the case load and working arrangements of the clinician. This should include discussion and review of: Core and associated membership attendance requirements Community and GPwER attendance requirements Documentation of decision making at MDTs should be completed in real time at the meeting and visible to the team for sign off MDTs should continue to meet for an operational meeting at least once a year. This Operational Policy should be reviewed along with the MDT workload, morbidity and mortality, audit, patient experience, trial recruitment and incorporate learning by combining this with presentations on relevant areas such as new treatments and guidelines MDTs should review their activity, performance and outcomes quarterly. Proactive demand management will reduce bottleneck pressures. Workload increases may require review of the frequency and time requirements The additional benefits of the MDT, e.g. education and involvement in clinical trials should be factored into assessment of the cost-effectiveness of the MDT.