Streamlining Multidisciplinary Team Meetings: Guidance for Cancer Alliances

This specialist Guidelines summary covers how multidisciplinary team meetings (MDTMs) can continue to provide effective clinical management by remaining focused on discussion of those patient cases that require full multidisciplinary input.

MDT streamlining will be supported by agreeing standards of care (SoCs) across Cancer Alliances. These SoCs will set out the treatment or care patients should expect to receive. Introducing MDT streamlining is not mandatory; however, it is recommended that Cancer Alliances work with Trusts locally to identify how this approach could benefit patients, clinicians, and MDTMs.

The principles set out here are not a one-size-fits-all approach and should be considered in relation to patient need, local circumstance, and by tumour site. Where Trusts introduce streamlining, this guidance must be followed.

Please refer to the full guideline for further information and case studies.

Successful Implementation of MDTM Streamlining

• MDT streamlining as set out in this guidance refers to the process of introducing SoCs as a routine part of MDTM to stratify patient cases into those that require full multidisciplinary discussion in the MDTM, and those cases that can be listed but not discussed in the MDTM, as patient need is met by an SoC.
• The following steps will support successful implementation of MDT streamlining:
  • the Cancer Alliance should work with site-specific clinical leads to identify MDTs in which to begin work on agreeing and introducing SoCs
  • SoCs should be developed and signed off by the relevant Cancer Alliance tumour pathway board, or equivalent, in collaboration with the clinical lead for that tumour site. These should draw on existing standards where possible
  • the Medical Director and lead cancer clinician at a Trust should sign off the SoC before they are implemented at Trust level. This is to ensure clinical oversight and buy-in to facilitate practice change
  • the MDTMs to which streamlining applies should be agreed at both Alliance and Trust level and done in agreement with all those involved in the pathway
  • a process for triage should be agreed at Trust level with approval from the Medical Director before SoCs are introduced, with roles and responsibilities set out for: referring clinicians, those involved in reviewing cases, and the MDT Chair. This may require adaptation of job plans
  • an approach to audit should be set out for each MDT before streamlining begins, to ensure that all information is captured and scheduled for review at appropriate intervals, including consideration of how patient representatives can contribute to audits
  • successful implementation of streamlining will require buy-in from all those involved in the patient pathway. Strategic oversight of implementation should be maintained and supported by Cancer Alliances which will ensure consistency across the geography. Clinical leads, operational managers, administrative staff, and patient representatives—as part of Alliances or tumour pathway boards—will need to collaborate to support practice change, ensuring that all those involved are clear about roles and responsibilities. Alliances and Trust leadership should work together to begin introducing streamlining when SoCs have been approved; this may include Executive Director sponsorship and oversight.

Developing Standards of Care for Streamlining

• Central to implementing MDTM streamlining is the introduction of SoCs. Providers and Alliances will already have predetermined SoCs in place for the diagnosis and treatment of (suspected) cancer patients. For the purposes of MDTM streamlining, these agreed standards must be formalised and strengthened to identify which patients do not require discussion at the MDTM.
• Existing SoCs should be drawn on where available and it is strongly encouraged to share SoCs between Alliances and Trusts to minimise duplication and promote consistency.

Definition: Standard of Care

• An SoC is a point in the pathway of patient management where there is a recognised international, national, regional, or local guideline on the intervention(s) that should be made available to a patient.
• There may be two or more recognised SoCs for a stage of disease or clinical scenario; a ‘watch and wait’ policy could be an SoC.
• SoCs are identified and drawn up by tumour site specialist MDTs with the Cancer Alliance Tumour Pathway Board. They must be referenced, signed off by the Cancer Alliance, and apply across the geography of an Alliance.
• Development of SoCs should focus on those points in the pathway where there is clear clinical consensus on the treatment or care that a patient should receive.

Developing National Standards of Care

• The NHS Cancer Programme will be working with professional bodies and Cancer Alliances to coordinate development of an initial set of SoCs. These will be shared through the Cancer Alliance Workspace online.

Developing Standards of Care in Cancer Alliances

• Cancer Alliances should utilise the Cancer Alliance Workspace online to coordinate and share further SoCs for adoption locally. This is central to promoting good practice, consistency in care, and avoiding duplication of effort between Cancer Alliances.
• Where further local SoCs are developed, the following steps must be completed for the SoC to be signed off by the Cancer Alliance:
  • identify the point in a predetermined SoC where referral to the MDTM is required, and incorporate NHS England’s rapid cancer diagnostic and assessment pathways, as well as local diagnostic protocols where applicable, to support the Faster Diagnosis Standard^[A]
  • clear clinical parameters for the application of the SoC, for example, histological sub-type, stage, and grade of disease, and therefore a patient does not require full discussion at MDTM. They should also give consideration to situations where an SoC would not apply with clear inclusion and exclusion criteria
  • SoCs should include processes for managing interactions of networked MDTMs and explicitly state to which MDTMs they apply; in some situations, they may apply to both local and specialist MDTMs. This is not a one-size-fits-all approach
  • the SoC identified must be based on national or international standards, guidelines and protocols, and best practice as determined by the Cancer Alliance Tumour Pathway Board. The clinical guidelines used in generating the pre-determined SoC must be referenced^[B]
• Each SoC must be approved for adoption by the Cancer Alliance Tumour Pathway Board, or equivalent, in collaboration with specialists in that tumour type, for example, from the specialist MDT in that patch.^[C] This should include discussion with patient representatives using local mechanisms.
• Examples of recognised SoCs within the NHS include NICE guidance and NHS England rapid cancer diagnostic and assessment pathways. Tumour types will vary in the number of recognised SoCs for different stages of disease and clinical scenarios. As such, streamlining is not a one-size-fits-all approach and will not necessarily apply to all patients.
• When looking to introduce SoCs, findings from the real-world testing of this guidance indicated that Cancer Alliances may wish to start with MDTs with the following characteristics:
  • tumour sites with well-established pre-defined treatment pathways, where there already exists clear consensus
  • local rather than specialist MDTs, where there may be a greater case mix, including fewer clinically complex cases that may require discussion
  • sub-specialist pathology and radiology expertise is already available to support triage of patients ‘not for discussion’ at the MDTM.

Updating Standards of Care

• SoCs should be reviewed by Cancer Alliances annually, or when there is a change to best practice in national or international guidance or clinical trial findings, whichever comes first. This ensures that they are up to date in relation to the latest guidance, published data, and national and international opinion on SoCs.
• Trusts should not amend the SoC as approved by the Cancer Alliance without explicit approval from the relevant Cancer Alliance Tumour Pathway Board (or equivalent).
• This is an ongoing process and it is expected that MDTMs will continually identify, approve and embed an increasing number of SoCs for different stages of disease and clinical scenarios.

Implementing Standards of Care in the MDTM

• SoCs must be introduced with support of the full MDT. With the streamlined approach, patients will be stratified by their consultant, or triage group, at the appropriate point of referral to the MDTM,^[D] to either: patient on an SoC (no discussion), or; patient requires discussion for any given reason, for example, patient preference. All patients remain accounted for through inclusion on the MDTM list.

Process for Implementing Streamlining

• The following steps will enable SoCs to be embedded in MDTMs:
  • all patients on a Cancer Alliance agreed pre-determined SoC must be listed at the full MDTM. No patient should be removed from oversight of the MDTM or responsibility of the MDTM
  • patients listed ‘not for discussion’ must have a completed minimum data set available (see Minimum core data requirements) which has been implemented as agreed by the Cancer Alliance Tumour Pathway board
  • if there is any doubt, any queries on a patient, or new information becomes available in advance of, at, or after the MDTM then the patient should be discussed at the MDTM; this could include physiological or psycho-social needs. Ability to refer the patient ‘for discussion’ is a safeguard for patient care
  • the MDTM should undertake a regular audit of patient cases not discussed in relation to the appropriateness of patients receiving an SoC and their outcome
  • implementing streamlining may require changes to processes across clinical, administrative, and management roles. It is important to engage all staff to raise awareness and collaborate to help the work to embed effectively.

Pre-MDTM Review of Cases

Approach to Reviewing Cases Prior to the MDTM

• Patients on an SoC should not require discussion at the full MDT meeting. For patients to be safely listed, there should be a clear process to collate essential information, and a minimum dataset must be available for each patient which pertains to the relevant tumour type.
• The minimum data set must have been reported and be available to the treating doctor. The decision to place a patient on the MDTM list will be made by the treating doctor or appropriate MDTM member as agreed locally. The responsibility for providing accurate information to the MDTM lies with the referring clinician in all cases. This information supports the recommendation of the MDTM, with any treatment decision made by the responsible clinician and patient.
• The SoC should be reviewed prior to the MDTM. This may be a named appropriate person, or some MDTMs may wish to create a ‘triage group’ for deciding which patients do not require full discussion at the MDTM. The MDT Chair should work closely with the coordinator and MDTM members to agree an optimal way to gather and review information in advance of the MDT meeting. The preferred means of reviewing patient cases ‘not for discussion’ in advance of the MDTM should be agreed with the Medical Director at the Trust and the method may vary between tumour sites.
• The purpose of a triage group should be focused on identifying whether patient need is met by the SoC or requires full MDT discussion. If such groups are formed their functionality and utility should be regularly reviewed and justified. The referring clinician maintains responsibility for their patients and the patient list should be made available for the MDT to review in good time before the meeting.

For a Patient to be Assigned for No Discussion at the MDT Meeting the Following Conditions Must be Met

• They have been seen, or the clinical circumstances otherwise assessed, by a core MDT member consultant or clinical nurse specialist (CNS).
• The minimum core data requirements have been met.
• The pathology has been reported by designated persons for that tumour type.
• Images have been reported by designated persons for that tumour type. Where imaging is outsourced, the reporting must be carried out by individuals agreed as suitable by the MDT.
• All other tests relevant to the decision-making have been completed.
• Patient preference stated (if known) and any special circumstances have been taken into consideration. Patients should be referred to the MDTM for discussion where preference contradicts an SoC pathway.
• The SoC has been reviewed by an appropriate person or triage group, there is clarity that it is appropriate, and all of the above have been fulfilled.

Minimum Core Data Requirements

• The following information must be accounted for in order to list a patient not for discussion at the MDTM:
  • diagnosis date (specify mode of diagnosis)
  • stage (specify investigations)
  • performance status
  • histopathological and/or cytological diagnosis
  • comorbidities
  • availability of, and suitability for, clinical trial/s
  • relevant genomic/genetic testing^[E]
  • patient preference (if known) and/or any special circumstances have been taken into consideration
  • MDTM recommendation and treatment pathway
  • any additional tumour-specific tests needed to inform diagnosis.
• These data items are from the Cancer Outcomes and Services Dataset (COSD).

National Data Collection for MDTM Streamlining

• At present, the COSD records every MDTM as well as care plan. As SoCs are introduced to facilitate streamlining of the MDTM, this process should also be captured in COSD.

Locally Agreed Protocols

• The minimum data should be supplemented by specific data items as required by cancer site, these may include:
  • molecular profiling as related to a particular cancer tumour
  • specific imaging protocols for a tumour site to ensure consistency of imaging across referral pathways
  • other fitness assessment parameters, for example, frailty assessment, as per SoC.

Clinical Trials

• Research is central to improving the health and care of the population. All patients, whether they are discussed in the full MDTM or their need is met by an SoC, should be considered for clinical trials. This should remain of central importance as MDTM streamlining is implemented.
• Each MDT must have access to an up-to-date list of clinical trials available, and cases not being discussed must be screened for potential suitability in liaison with one of the National Institute for Health and Care Research 15 Local Clinical Research Networks.

Personalised Care

• The NHS Long Term Plan sets the ambition to offer personalised care to all cancer patients and transform follow-up care, giving people choice and control over the way their care is planned and delivered. MDT streamlining should support the drive for personalisation and ensure that shared decision-making in care, and personalised care and support planning, are routine for all patients.
• Personalised care and support planning (based on a Holistic Needs Assessment) ensures focus on what matters to the individual and their strengths, needs and preferences. Resources to support these conversations are available online on the NHS England and NHS Improvement website, and General Medical Council guidance sets out expectations on including patient preferences into the decision-making processes around care.

Audit

• For safe and effective introduction of pre-determined SoCs, the audit processes set out in the sections below must be embedded before SoCs can go live.

Streamlining and National Guidelines

• Where MDTs introduce streamlining as set out in this guidance they will remain compliant with the relevant quality surveillance indicators relating to scheduled treatment planning MDTMs.
• 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 members. The detail of required roles and what constitutes a quorum is set out nationally in the quality surveillance quality indicators and service specifications, where applicable.
• Trusts should continue to work to the latest national standards in reviewing and investigating deaths of patients; this is set out in guidance from the National Quality Board, and MDTs should continue to monitor 30-day mortality at the appropriate mortality meetings and maintain oversight of relevant data.

Local Audit of SoCs at the MDTM

• Audit of MDTM outcomes and processes is central to the assurance of standards. Regular audit of cases to the MDTM should also take place so that the new way of working can be reviewed for learning purposes; audit subjects, outlined in the Annex of the full guideline, are compulsory to facilitate learning between Alliances, Cancer Centres, and MDTMs within the same centre. Teams must ensure that, as any changes are brought into effect, the quality of data collection and input is maintained as this remains critical for the Cancer Registry and other data collection.
• Findings should be reported to the Cancer Alliance Tumour Pathway Board (or equivalent) and Clinical Directors and used for a continual cycle of improvement to pre-determined SoCs and processes. This should include a conversation with patient representatives to the pathway board to discuss findings. MDTs may want to identify a data lead to support collation of audit data.

Frequency of Audit

• MDTMs should review a sample of patient data quarterly, covering both patients on pre-determined SoCs, and those referred for discussion at the MDTM.
• This will not replace pre-existing arrangements for annual operational meetings for MDTMs. Process and outcomes of the audit should be documented.
• The regular audit of patient cases can be phased to less frequent 6- or 12-monthly audits if the following conditions are met:
  • it is a clinically led decision by members of the MDT when the process of streamlining has become routine practice
  • it includes consideration of acceptable audit findings
  • it is done in agreement with the Medical Director and Lead Cancer Clinician.

Topics for Inclusion in Audit

• Audit meetings should cover both clinical and operational functioning of the streamlining MDT meeting. Topics for inclusion are outlined in Table 1. Teams should ensure that they consider the needs of patients with protected characteristics, including those groups of people who are not usually provided for by healthcare services, such as rough sleepers, vulnerable migrants, and people living in the most deprived areas and geographies, for example, rural areas, as we know where people live impacts on how much they will engage with treatment and care.

The MDT Meeting as a Learning Opportunity

• The introduction of SoCs to MDTMs provides an opportunity to contribute to the MDT as a place for learning. There are a number of ways that streamlining could be utilised, including: scenario-based team meetings linked to audit; a quarterly ‘learning’ MDT where a sample of listed cases are included for discussion; presentation of clinical audit by an information or data lead, and; inclusion of, for example, trainees or CNSs, in the pre-MDT triage process.

Next Steps and Implementation

• Cancer Alliances should work with Trusts and clinicians in their patch to identify appropriate tumour sites and MDTs in which to begin streamlining. It is suggested that sites begin to introduce streamlining in first selected sites within 6 months.
• To support implementation, the NHS Cancer Programme will be working with professional bodies and Alliances to coordinate development of an initial set of SoCs. These will be shared through the Cancer Alliance workspace online. Cancer Alliances should utilise the Workspace to coordinate and share development of further SoCs for adoption locally. This is central to promoting good practice and avoiding duplication of effort between Alliances.
• Cancer Alliances will play an ongoing role in monitoring the uptake and outcomes of streamlining MDTMs. The content for audit meetings as well as data from COSD should be considered for an annual report to the Cancer Alliance Board, which can also help to inform the roll-out of the Faster Diagnosis Standard and timed pathways.
• Quarterly audit meetings should cover, but not be limited to, the following topics:

Table 1: Topics to Cover in a Quarterly Audit Meeting (Not Exhaustive)

Footnotes

[A] Further diagnostic protocols, where clinically recognised and referenced, may also be applicable.
[B] This information should already be available as part of the MDTM’s operational policy in the treatment pathways and guidelines as per Quality Surveillance indicators.
[C] This does not preclude further input, or oversight, from relevant bodies such as Clinical Quality Groups to support development and rollout.
[D] Where available, referral to the MDTM should align with NHS England’s rapid cancer diagnostic and assessment pathways.
[E] Where a genomic test is likely to have a material impact on treatment planning, the patient should normally be discussed either at a genomic MDT or other MDT meeting.