MDT working in Great Britain

1. MDT working in Great Britain Rob Glynne-Jones Mount Vernon Cancer Centre

2. The doctor: Samuel Luke Fildes

4. I have 5 MDTs each week/1 monthly • 2 upper GI • 2 lower GI/colorectal • 1 HPB • 1 anal (2-4 weekly) • 4 separate times in week • Total 5.25 hours +Travel time 1.5 hours +preparation 1.25 hour total 8 hours = 20% of basic contract

5. NICE Guidance • Patients should be discussed in MDTS to improve treatment standards and decision making “ the care of all patients with cancer should be formally reviewed by a specialist team” “All patients have the benefit of the range of expert advice for high quality care” The NHS Cancer Plan and the New NHS 2004 Now over 1500 MDTS

6. NHS National Cancer Action Team • The characteristics of an effective multidisciplinary team February 2010 (6 years later!) - based on 2000 replies www.ncin.org.uk/mdt

7. Survey MDT www.ncin.org.uk/mdt

8. MDTs should result in • Treatment and care by professionals with specialist knowledge • Opportunity to enter relevant clinical trials • Patients assessed and offered appropriate information and support • Continuity of care • Communication between primary, secondary and tertiary care

9. MDTs should result in • Good data collection • Adherence to national and local guidelines • Good working relationships • Opportunities for education • Optimisation of resources

10. NHS core contract with Trusts • By March 2011 Trusts should deliver basic patient data to cancer registries

11. There should be • Dedicated MDT room • Access to imaging • Access to projection of pathology • Connection to PACS • Access to database/proforma for realtime documentation of decisions • Organisation support (co-ordinator)

12. What is an MDT? - Attendance • 2004 Manual for Cancer Services - MDT comprises Core and extended members • Core (all consultants involved in the elective care of a patient) • Core are expected to attend 50% of meetings • Peer review examines register of attendance

13. What constitutes the MDT? • Is there a minimum number to be quorate? • Does every discipline need to represented (I have no deputy) • In practice we call off an MDT if there will be no surgeons • ? Data collected • ? Decisions made

14. The Best MDT I do • Fun (the bit of the week I enjoy most) • Attendance excellent - all members • Stimulating – I learn, I teach • I value the discussion (difficult cases) • Supportive of each other • Constructive when things go wrong – not minuted - no blame • I can access results/decisions if I am not there

15. Costs of a MDT • Audit of Attendance at 14 MDTs over one week in Leeds • 147/294 consultants attended • 10/43 junior doctors • 41/100 others • 2.14 hours per MDT • Costed in salaries as £15,808 Fosker and Dodwell Bmj 2010

16. Costs of a MDT • Staff costs approx £1000 • Total number of patients discussed 431 • Per patient £36 NB Excludes preparation costs (Radiology and Pathology) Bmj.com/cgi/eletters/340/mar23_2/c951#239579

17. MDT Decisions • Who records the decisions? • What is the system? Paper or electronic? • Are the decisions readily accessible? (EPR) • What about other disciplines in hospital? • How quickly are decisions reported to patient? • How quickly are decisions reported to GP?

18. Non-technical factors • Who is due to attend? • Who actually attends? • Who is chairing (and does this rotate?) • Does it work as a team? • Is discussion open? • Is there consensus?

19. Patient views on MDT • Majority feel comforted that experts have all been involved • Others feel aggrieved that they have been discussed and decisions made without them • More comfortable when specialist nurse intimately involved as liaison

20. Working as a team • Ensures all patients discussed • Brings in evidence base • Rationalisation of care • Appropriate treatments for appropriate patients • Stabilising influence of the majority • You change and adapt

21. The MDT is good at collecting • Data on clinical staging • Data on treatment • Data on surgical morbidity • Data on cancer outcomes

22. The MDT is not good at collecting • Data on patient PS • Data on patient co-morbidities • Data on patient mental state • Data on chemotherapy toxicity • Data on radiation toxicity

23. Some MDTs show a photo of the person to be discussed

24. Technical factors • Patient information/ notes/ clinician responsible • Radiological access and expertise • Pathological access and expertise • Videoconferencing??????

25. Technical factors • Documentation of decision • Implementation of decision • Informing other agencies GP/ palliative care etc..

26. Building a team • Takes time • Takes effort • Means working together • Understanding the value of each others roles

27. Building a team • Does everyone have an equal say? • Does everyone carry equal weight? • Does the chair rotate? • Knowing/recognising your own role • Knowing/recognising how our failure impacts on others in the team

28. What practice is most important? • Respecting each other and each others contribution • Rather than exclude less effective members, include and improve all members of the team to a good level • Co-operating and not competing with one another • Teaching and passing on skills • Taking time out with the team to discuss issues together • Being prepared to change and revise ways of working together

29. What qualities are important in the chair? • Being consistent and fair to everyone • Creating a good working atmosphere • Fostering a team identity • Being constructive especially if things have not gone well

30. Criticisms of the MDT • Committee decisions don’t work

31. What happens if you get a committee to design a horse ??

32. Criticisms of the MDT • Committee decisions don’t work • Too often personal animosities cloud the issues

33. The Multidisciplinary Team Meeting

34. Criticisms of the MDT • Committee decisions don’t work • Too often personal animosities cloud the issues • Some members feel threatened by the surgeons

36. Criticisms of the MDT • Committee decisions don’t work • Too often personal animosities cloud the issues • Some members feel threatened by the surgeons • Discussion when you have not seen the patient • You are bound by MDT decision whatever??

37. My advice - AVOID! • Tyranny • Personal criticism • Forcing individuals into making personal decisions • Too big MDTs – numbers mean no time for discussion ie rubber-stamping exercise • Videoconferencing the routine patients

40. My advice - Ensure! • A good chair or rotate the chair • Good co-ordinator • Clinical nurse specialist for liaison • Easy access to MDT • Keep it manageable ie time for discussion/teaching/trials/ research • Invite other specialist rather than Videoconferencing

41. Thank you