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MDT working in Great Britain. Rob Glynne-Jones Mount Vernon Cancer Centre. The doctor: Samuel Luke Fildes. 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

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Mdt working in great britain l.jpg

MDT working in Great Britain

Rob Glynne-Jones

Mount Vernon Cancer Centre



I have 5 mdts each week 1 monthly l.jpg
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


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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


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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


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Survey MDT

www.ncin.org.uk/mdt


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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


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MDTs should result in

  • Good data collection

  • Adherence to national and local guidelines

  • Good working relationships

  • Opportunities for education

  • Optimisation of resources


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NHS core contract with Trusts

  • By March 2011 Trusts should deliver basic patient data to cancer registries


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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)


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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


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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


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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


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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


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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


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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?


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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?


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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


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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


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The MDT is good at collecting

  • Data on clinical staging

  • Data on treatment

  • Data on surgical morbidity

  • Data on cancer outcomes


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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



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Technical factors

  • Patient information/ notes/ clinician responsible

  • Radiological access and expertise

  • Pathological access and expertise

  • Videoconferencing??????


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Technical factors

  • Documentation of decision

  • Implementation of decision

  • Informing other agencies GP/ palliative care etc..


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Building a team

  • Takes time

  • Takes effort

  • Means working together

  • Understanding the value of each others roles


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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


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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


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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


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Criticisms of the MDT

  • Committee decisions don’t work



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Criticisms of the MDT

  • Committee decisions don’t work

  • Too often personal animosities cloud the issues



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Criticisms of the MDT

  • Committee decisions don’t work

  • Too often personal animosities cloud the issues

  • Some members feel threatened by the surgeons


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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??


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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


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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



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