Defining an evidence-based strategy for streamlining cancer multidisciplinary team meetings.

Throughout its history, the National Health Service (NHS) in the UK has undergone numerous reforms. One such historical transformation occurred in cancer care in the mid-1990s, spurred by below-average survival rates, variability in treatment quality, and fragmented care. In response, the UK Government prioritised enhancing care quality and survival, with the Calman-Hine report1Calman K Hine D A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to Chief Medical Officers of England and Wales. Department of Health and Social Care, London1995https://iiif.wellcomecollection.org/pdf/b3221926xDate accessed: August 14, 2023Google Scholar in 1995 and the NHS Cancer Plan2UK Department of HealthThe NHS Cancer Plan. A plan for investment. A plan for reform.https://dera.ioe.ac.uk/id/eprint/4423/1/04055783.pdfDate: July, 2000Date accessed: August 14, 2023Google Scholar in 2000 guiding the efforts. These strategic documents promoted an integrated and coordinated approach to cancer care and a move towards cancer-specific specialists within cancer multidisciplinary teams. The focus shifted from introducing new health technologies to improve patient care to revamping the infrastructure and prioritising human factor dynamics—specifically, the interactions and collaborations between specialists within care teams. Although some of the reform's underpinnings have been debated since—particularly the notion that specialisation and concentration of expertise (with high caseloads) would lead to better outcomes for patients—the Government showed its commitment to cancer care by investing substantial resources in its roll-out between 1995 and 2020.1Calman K Hine D A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to Chief Medical Officers of England and Wales. Department of Health and Social Care, London1995https://iiif.wellcomecollection.org/pdf/b3221926xDate accessed: August 14, 2023Google Scholar, 2UK Department of HealthThe NHS Cancer Plan. A plan for investment. A plan for reform.https://dera.ioe.ac.uk/id/eprint/4423/1/04055783.pdfDate: July, 2000Date accessed: August 14, 2023Google Scholar, 3Morris E Haward RA Gilthorpe MS Craigs C Forman D The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients.Br J Cancer. 2006; 95: 979-985Crossref PubMed Scopus (91) Google Scholar The multidisciplinary team meeting became central to the implementation of the 1995 reform and a gold standard in cancer care.1Calman K Hine D A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to Chief Medical Officers of England and Wales. Department of Health and Social Care, London1995https://iiif.wellcomecollection.org/pdf/b3221926xDate accessed: August 14, 2023Google Scholar, 2UK Department of HealthThe NHS Cancer Plan. A plan for investment. A plan for reform.https://dera.ioe.ac.uk/id/eprint/4423/1/04055783.pdfDate: July, 2000Date accessed: August 14, 2023Google Scholar, 3Morris E Haward RA Gilthorpe MS Craigs C Forman D The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients.Br J Cancer. 2006; 95: 979-985Crossref PubMed Scopus (91) Google Scholar Its pivotal role in improving care quality and reducing treatment variations has since been reinforced by generally supportive evidence.4Lamb BW Brown K Nagpal K Vincent C Green JSA Sevdalis N Quality of care management decisions by multidisciplinary cancer teams: a systematic review.Ann Surg Oncol. 2011; 18: 2116-2125Crossref PubMed Scopus (314) Google Scholar, 5Soukup T Lamb BW Morbi A et al.A multicentre cross-sectional observational study of cancer multidisciplinary teams: analysis of team decision making.Cancer Med. 2020; 9: 7083-7099Crossref PubMed Scopus (19) Google Scholar, 6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar The multidisciplinary team meeting provides value through a formal, dedicated setting for the cancer-specific specialists to meet regularly to methodically review cases, provide specialist knowledge, and collectively formulate treatment recommendations.1Calman K Hine D A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to Chief Medical Officers of England and Wales. Department of Health and Social Care, London1995https://iiif.wellcomecollection.org/pdf/b3221926xDate accessed: August 14, 2023Google Scholar, 2UK Department of HealthThe NHS Cancer Plan. A plan for investment. A plan for reform.https://dera.ioe.ac.uk/id/eprint/4423/1/04055783.pdfDate: July, 2000Date accessed: August 14, 2023Google Scholar, 3Morris E Haward RA Gilthorpe MS Craigs C Forman D The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients.Br J Cancer. 2006; 95: 979-985Crossref PubMed Scopus (91) Google Scholar, 4Lamb BW Brown K Nagpal K Vincent C Green JSA Sevdalis N Quality of care management decisions by multidisciplinary cancer teams: a systematic review.Ann Surg Oncol. 2011; 18: 2116-2125Crossref PubMed Scopus (314) Google Scholar, 5Soukup T Lamb BW Morbi A et al.A multicentre cross-sectional observational study of cancer multidisciplinary teams: analysis of team decision making.Cancer Med. 2020; 9: 7083-7099Crossref PubMed Scopus (19) Google Scholar, 6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar However, the landscape of cancer care is now at another historic crossroad. Growing demands on multidisciplinary team meetings, driven by increasing cancer incidence in an ageing population, complex diagnostic and treatment modalities, and fiscal and workforce constraints, are straining the system.5Soukup T Lamb BW Morbi A et al.A multicentre cross-sectional observational study of cancer multidisciplinary teams: analysis of team decision making.Cancer Med. 2020; 9: 7083-7099Crossref PubMed Scopus (19) Google Scholar, 6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar, 7Hoinville L Taylor C Zasada M et al.Improving the effectiveness of cancer multidisciplinary team meetings: analysis of a national survey of MDT members' opinions about streamlining patient discussions.BMJ Open Qual. 2019; 8e000631Crossref PubMed Scopus (29) Google Scholar Recognising these challenges, NHS England's 2016 cancer strategy and Cancer Research UK in 2017 called for caseload streamlining to conserve time and resources, while ensuring specialists focus on more complex cases. This directive heralded a historic shift in cancer care planning, marked in 2020 by the release of the NHS England streamlining guidance.6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar For the first time since the mid-1990s, it became no longer mandatory for all cancer cases to be discussed at multidisciplinary team meetings. Now, only complex cases requiring multidisciplinary input require detailed discussion in multidisciplinary team meetings, while patients on predetermined pathways need to be registered but not deliberated by the multidisciplinary team.6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar Although streamlining offers a potential solution5Soukup T Lamb BW Morbi A et al.A multicentre cross-sectional observational study of cancer multidisciplinary teams: analysis of team decision making.Cancer Med. 2020; 9: 7083-7099Crossref PubMed Scopus (19) Google Scholar, 6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar to challenges confronting multidisciplinary team meetings, there is a scarcity of published evidence that the NHS England streamlining guidance6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar has been adopted widely since its release in 2020—a situation that could amplify inequitable access to proven and innovative treatments. There is a concern that without evidence-based strategies to streamlining, we risk reintroducing the very inconsistency in patient care that multidisciplinary team working was designed to eliminate after the Calman-Hine report.8Winters DA Soukup T Sevdalis N Green JSA Lamb BW The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives.BJU Int. 2021; 128: 271-279Crossref PubMed Scopus (22) Google Scholar, 9Soukup T Lamb BW Sevdalis N Green JS Streamlining cancer multidisciplinary team meetings: challenges and solutions.Br J Hosp Med. 2020; 81: 1-6Crossref Scopus (19) Google Scholar Adopting an evidence-based approach will ensure that patient safety and care quality are uncompromised,7Hoinville L Taylor C Zasada M et al.Improving the effectiveness of cancer multidisciplinary team meetings: analysis of a national survey of MDT members' opinions about streamlining patient discussions.BMJ Open Qual. 2019; 8e000631Crossref PubMed Scopus (29) Google Scholar, 8Winters DA Soukup T Sevdalis N Green JSA Lamb BW The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives.BJU Int. 2021; 128: 271-279Crossref PubMed Scopus (22) Google Scholar, 9Soukup T Lamb BW Sevdalis N Green JS Streamlining cancer multidisciplinary team meetings: challenges and solutions.Br J Hosp Med. 2020; 81: 1-6Crossref Scopus (19) Google Scholar and address the reported apprehension of multidisciplinary teams to streamlining,7Hoinville L Taylor C Zasada M et al.Improving the effectiveness of cancer multidisciplinary team meetings: analysis of a national survey of MDT members' opinions about streamlining patient discussions.BMJ Open Qual. 2019; 8e000631Crossref PubMed Scopus (29) Google Scholar thus facilitating consistent adoption of the guidance.6NHS England and NHS ImprovementStreamlining Multi-Disciplinary Team Meetings – Guidance for Cancer Alliances.https://www.england.nhs.uk/wp-content/uploads/2020/01/multi-disciplinary-team-streamlining-guidance.pdfDate: 2020Date accessed: August 14, 2023Google Scholar With the crucial need to streamline multidisciplinary team meetings, we propose an evidence-based research effort grounded in implementation science to minimise risks and maximise learning. Implementation science can drive rapid and effective translation of the streamlining guidance into practice, ultimately enhancing care quality and patient survival. First, the effectiveness of streamlining approaches and strategies against implementation, patient, and service outcomes, should be evaluated with validated tools.9Soukup T Lamb BW Sevdalis N Green JS Streamlining cancer multidisciplinary team meetings: challenges and solutions.Br J Hosp Med. 2020; 81: 1-6Crossref Scopus (19) Google Scholar, 10Soukup T Morbi A Lamb BW et al.A measure of case complexity for streamlining workflow in multidisciplinary tumor boards: mixed methods development and early validation of the MeDiC tool.Cancer Med. 2020; 9: 5143-5154Crossref Scopus (19) Google Scholar This adds value by revealing unintended consequences, both positive and negative, ensuring that streamlining is implemented effectively and safely. Second, data on the facilitators and barriers to streamlining should be collected systematically. This will inform development of effective implementation strategies and approaches, ensuring consistent adoption of streamlining. Third, drawing on methodologies such as Getting it Right the First Time (GIRFT), the identification of strategies and approaches to streamlining that work, those that do not, and the circumstances under which they succeed or fail should be recorded systematically. Finally, building on GIRFT's success, in particular recent GIRFT Guidance for Kidney Cancer, and British Association of Urological Surgeons Guidance on Implementing Streamlining in Urology multidisciplinary team meetings, data-driven insights from in-depth reviews of streamlining should be converted into a practical gold standard implementation manual for multidisciplinary team meetings across different tumour types, containing: identified and anticipated determinants to streamlining; effective implementation strategies and instructional procedures, enriched by real-world case scenarios (akin to those adopted by, for example, the Civil Aviation Authority's CAP737: Flight Crew Human Factors Handbook); and a toolkit equipped with validated instruments for evaluating the impact of streamlining and promoting a culture of continuous improvement and audit. As we navigate this transformative phase in cancer care, it is crucial that streamlining remains rooted in evidence-based strategies and approaches. Building on the legacy of the Calman-Hine report,1Calman K Hine D A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to Chief Medical Officers of England and Wales. Department of Health and Social Care, London1995https://iiif.wellcomecollection.org/pdf/b3221926xDate accessed: August 14, 2023Google Scholar we should strive to combine historical lessons, evidence-based methodologies, and future-forward strategies, ensuring equitable, and consistently high-quality care for every patient with cancer. GDS and BWL contributed equally to this work. Infrastructure support for this research for TS was provided by NIHR London Medtech and In vitro diagnostic Co-operative. BWL and TS received funding from Cancer Alliances and NHS England for training multidisciplinary teams in assessment and quality improvement methods in the UK and honoraria for public speaking from Parsek. TS received consultancy fees from Roche Diagnostics, Parsek, and Salutare. BWL received consultancy fees from Digital Surgery, MDOUTLOOK and honoraria from AstraZeneca and Astellas, and has a leadership role in the British Association of Urological Surgeons (Section of Oncology). GDS received educational grants from Pfizer, AstraZeneca, and Intuitive Surgical; consultancy fees from Pfizer, Merck, EUSA Pharma, and CMR Surgical; and travel expenses and speaker fees from Pfizer. GDS also has a leadership role in GIRFT (kidney cancer guidance), NICE kidney cancer guideline, and the National Kidney Cancer Audit.