By Dr Majid Kazmi, Consultant Haematologist and Director of Research, Innovation, Commercial and Digital for Cancer and Surgery, Guy’s and St Thomas’ NHS Foundation Trust, speaking in his personal capacity
In some cancer multidisciplinary team meetings, a case now gets less than ninety seconds. This is nowhere near enough time to do justice to anyone’s cancer, and I’m sure every clinician sitting in those meetings would agree.
The volume has grown for good reasons, because the drive towards earlier diagnosis and an ageing population are putting more people through cancer pathways, and patients who have relapsed are coming back with treatment options that did not exist a few years ago. This is positive progress but has put increased pressure on a meeting that is no longer sustainable.
Not all the pressure is unavoidable. Cases are routinely listed before anyone has confirmed that the tests are done and the results are back, which accounts for a re-discussion rate of 10-15%, and the MDT has become a place to share medicolegal risk as much as a place to decide treatment.
Cancer Research UK found as long ago as 2017 that MDT meetings in England had increased by 20%, while workforce numbers had barely changed. NHS England published streamlining guidance for cancer alliances in January 2020, the Royal College of Radiologists led a multi-society call for a radical overhaul last year, and the National Cancer Plan has since asked the College to review how MDTs should be modernised, with new guidance not expected until spring 2027.
That is a decade of agreement about the direction of travel, and still nobody has said how the meetings should be streamlined.
A victim of its own success
It’s worth remembering why MDTs were set up, because before they existed there was little to guide the best treatment for a patient and the variation in what people were offered was enormous. MDT discussion became mandatory in Cancer pathways to reduce this variation in care and encourage best practice.
Since then, however, we now have well established guidelines covering most of what comes through the door, and where a case is straightforward there is a reasonable argument for following the guideline and moving on. What has not kept pace is the record keeping, since there is no systematic way of auditing which patients went through an MDT and which went straight to standard of care.
Strategy without a delivery plan
The gap between ambition and delivery reflects a wider habit in healthcare, where strategic documents set a direction and avoid prescription. Guidance will say that teams should consider electronic tools for their MDTs, but it does not mandate anything, and it does not tell a clinical director what they are expected to have achieved by next April. The technology is not the missing piece, since tools that stratify cases against an agreed standard are already in live NHS use.
Strategy becomes delivery at the point where somebody sets a parameter, which means working region by region to create a framework with targets attached. A cancer alliance could establish from its own data what reduction is achievable across its tumour groups and then set that as the expectation. How teams get there would remain a local decision, but having a measurable target that you are accountable for is what turns a direction of travel into something a clinical service can plan around.
Firmer measures are surely coming, and trusts will be asked to demonstrate they have decompressed their MDTs. It is better to have a locally evidenced and considered implementation plan than have a solution forced on you. This way you are more likely to get clinician buy-in.
Deciding which cases need the room
The practical question is where the line falls, and a patient who fits the criteria neatly does not need a room full of different specialists to confirm what the guideline already says. A patient who does not fit neatly is another matter, because where there is a comorbidity that may preclude surgery, or a medication that may interact with the planned treatment, no guideline covers the situation cleanly and you need the consensus view of the right experts. That consensus no longer requires everyone in the same room at the same time though. Technology provides more efficient ways of contributing to collective decision making since colleagues can contribute asynchronously without the need to be in a physical or virtual meeting at the same time.
Those discussions should record a clear clinical rationale for departing from the guidance, and what proportion of cases that leaves to be discussed in a face-to-face MDT will vary between tumour groups.
What the prostate cancer work taught us
The way to find your own line is to test it, and at Guy’s and St Thomas’ we spent two years evaluating the Deontics decision support tool in prostate cancer, running a retrospective analysis, then a shadow period alongside the live MDT, then a prospective phase to define which patients met standard of care criteria and could come out of the meeting altogether.
The tool agreed with an expert panel’s consensus on 92% of retrospective cases, and running alongside 400 live patients, it picked out a third as suitable for streamlining while matching the MDT’s own recommendation more than 96% of the time. Where the two diverged it was usually because a recommendation made two years earlier had been reasonable at the time and the guidance had since moved on. An electronic tool is updated centrally, and every user gets the change at once which saves significant time and effort currently consumed in local guideline updating.
The modelled saving is around £130,000 a year on one pathway, and prostate triage now runs live at Guy’s with breast cancer next where the benefits are expected to be even greater in terms of reduced cases needing traditional MDT discussion. Early conversations are being held about extending to bladder cancer and melanoma with other tumour groups to follow. There is unpublished evidence that formal MDT’s lose money for a healthcare provider as the number of cases being discussed outstrips the historic funding arrangements.
An extra voice in the room
Decision support is not diagnosis, but a way of gathering the information and offering a view on the best intervention and used well, it becomes an extra voice in the room that can point out where the latest guidance differs from the decision the team has just reached. Clinicians need to get comfortable with that challenge, because the knowledge base is moving faster than any of us can follow.
Trusts don’t need to wait for a report to begin, so pick a tumour group, run the analysis and set your own expectation for how many cases should be leaving the face-to-face meeting. This clinical optimisation of the MDT pathway is what takes the most time before a tool can be deployed live.
The good news is that Guy’s & St Thomas’ and others have already done much of this work and so other healthcare providers don’t need to reinvent the wheel. Using digital tools like Deontics makes MDT meetings, auditable, sustainable and most importantly protects the time for the cases that genuinely need the experts in the room, which is what the MDT was created for.