Reassessing the efficiency and functions of multidisciplinary teams for cancer
After more than 20 years since multidisciplinary teams were introduced, a damning new report looks into the usage by people with cancer, as more are being diagnosed than ever before.
More than 20 years have passed since the introduction of multidisciplinary team working in cancer. Throughout that time they have been seen as the gold standard for cancer services.
By bringing together a range of experts in a weekly meeting, all aspects of the patient’s care and needs can be considered... or so the theory goes.
Earlier this year a report by Cancer Research UK (CRUK), which involved observing more than 600 multidisciplinary team (MDT) discussions and surveying more than 3,000 MDT members, raised several worrying issues.
The increasing number of cancer diagnoses has meant that the volume of patients discussed at meetings has ballooned – and this has happened at a time when care is becoming ever more complex.
of prostate cancer nurses say their MDT is not functional or efficient
CRUK's report said it has led to meetings lasting several hours with some taking as many as five hours. Yet the average discussion time was just 3.2 minutes with more than half lasting less than two minutes.
The result is that there is little time for wider input from all healthcare professionals – the goal that MDTs were set up to achieve.
The report found that the average number of people involved in each discussion was just three, while in only 14% of cases did the discussion broaden beyond the specifics of the tumour to issues such as the patient’s preference, co-morbidities or psychosocial status.
This is not that surprising when you consider that in more than three quarters of meetings there were no verbal contributions from nurses.
But why is this? A clue can be found in the research done by London South Bank University (LSBU). It maintains a database of 18,000 specialist nurses, covering a wide range of cancers and other disease areas.
The team has been monitoring their working lives for ten years and in September published a report highlighting the problems facing prostate cancer nurses.
Researchers received feedback from nearly 300 clinical nurse specialists on MDT working and found there was poor cohesion between team members, a lack of respect and increasing time pressures. The situation resulted in a lack of interest in non-medical concerns and an inability to constructively challenge medical opinion.
More than half of the nurses who took part felt they did not work in a functional and efficient MDT.
The average length of discussion about a patient during MDT meeting
LSBU chair of healthcare and workforce modelling Alison Leary says there are some unique differences with the way prostate cancer nurses work compared with their peers who specialise in other types of the disease in that their time tends to be divided between cancer and general urology.
But she says that while prostate cancer MDTs are ‘probably the extreme examples’ the problems certainly exist across the board in some form.
Professor Leary says: ‘Workload is becoming a real problem. Nurses are saying there just isn’t the time in the meetings or outside of the meetings to discuss everything because of the volume of the work – so it is the medical side that gets prioritised.
She says LSBU’s wider work also suggests there has been a shift towards specialist nurses being appointed on lower bands – with examples of band 4 staff working in nursing roles for MDTs in the database.
‘More experienced nurses feel more able to speak up and challenge,’ she says.
However she adds that even experienced nurses can find it difficult as the age-old problems with hierarchy ‘with doctors at the top’ still persists.
Case study: The benefits of a functional multidisciplinary team
Sarah Orr is the lead clinical nurse specialist for head and neck cancer at University College London Hospitals NHS Foundation Trust.
‘By working in MDTs we can treat the whole patient rather than just the disease. You can look at the diagnosis and say "this patient needs surgery", but that does not take into account other factors, like their personal situation or their mental health. Good MDT working allows things like that to be taken into account and benefits the patient.’
Her MDT meets once a week, for about two hours, and usually involves at least 30 health professionals, including four nurses.
‘We discuss 35 to 40 patients each time. It is a lot more than we used to do a few years ago. It makes it hard, some will be post-operative or post-treatment and won’t need a great deal of discussion, but others will. It is common for us to agree to take some conversations offline and follow up after the meeting.
‘We have a good team here and we all value MDT working. That is essential. You need to show everyone respect and value the input of the whole team and get them contributing.’
UK Oncology Nursing Society past president Richard Henry agrees. He says doctors too often have a different understanding of what MDT working is, seeing it as a discussion between surgery, radiology and oncology.
But he says because of the numbers and complexity of the patients now presenting, multi-professional input was needed ‘more than ever’.
‘The aim is to provide person-centred care and that requires the input of nurses. They are the advocates for patients.’
He says there is hope that things will change – NHS England has set up a review of MDT working which is currently gathering evidence.
Mr Henry says: ‘There’s talk of having separate meetings for diagnosis and for treatment planning. There’s also talk of triaging patients. Both have merits, but we have to think carefully. What criteria would we use for triaging for example?’
He also believes there needs to be more research done on how decisions made at the MDT meeting are coordinated afterwards.
NHS England is not the only organisation to be looking at this though.
University College London Hospitals Cancer Collaborative, which incorporates cancer services across parts of north London and Essex, recently produced a report on how to improve MDT working.
A research group looked at 13 different teams and made a number of recommendations to improve working.
These included improving the quality of information on the pro forma by making sure it captured information about the tumour, possible treatment, suitability for trials and holistic information (from patient preferences to other health conditions) to allow informed decisions to be taken.
3 in 4
MDT meetings have no verbal contribution from nurses
The group also suggests busy MDTs can free up time by prioritising the most complex cases and relying on established treatment plans – known as protocolised pathways – for the less complex ones.
Regular reviews of how the MDTs are working could be held outside of weekly meetings, it also suggests, to ensure they remain efficient and well functioning.
UCLH Cancer Collaborative nursing board chair Alison Hill says the problems identified have been building for some time, but were ‘exacerbated’ by patient volume.
'Now is the time to act', she says. ‘MDTs still work, because staff make them work, but we need to reassess how they run.’
- CRUK MDT report
- University College London Hospitals Cancer Collaborative MDT report
- Clinical Nurse Specialist Journal (2017) The Experiences of Specialist Nurses Working within the Uro-oncology Multidisciplinary Team in the United Kingdom
Nick Evans is a freelance health writer