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Dr Tom Oakley, CEO, Feedback Medical on the future of multi-disciplinary teams

By Dr Tom Oakley, CEO, Feedback Medical

Multidisciplinary teams (MDTs) have been at the heart of good clinical practice in England since the landmark Calman-Hine report on cancer services in 1995. The basic idea is still right: clinicians work much more effectively together rather than in professional silos. But in practice MDTs have become unfit for purpose: too big, too long and poorly served in terms of information.

Fortunately, new technology such as Bleepa can free MDTs from these frustrations and enable them to deliver fast, effective, joint decision-making. Crucially, team members can log their opinions and comment on those of their colleagues without having to be in the same room at the same time. New technology will deliver MDTs as they were originally envisaged, to the great benefit of both clinicians and patients.

Why MDTs?

MDTs became an established part of NHS medical practice following the “Policy Framework for Commissioning Cancer Services” authored by the chief medical officers of England and Wales, Dr Kenneth Calman and Dr Deidre Hine – now simply known as the Calman-Hine Report.

Literature had shown the effectiveness of multidisciplinary teams in improving survival and quality of life. MDTs would be the heart of new Cancer Centres, whether that team was concentrated on one site or many:

“The Cancer Centre represents a centralisation of expertise of many disciplines and it is desirable that it should be brought together in one hospital or by one administrative structure … Where it is not possible to concentrate all expertise in one site, close collaborative structures and managerial integration are needed with the identification of lead clinicians appointed to ensure the development and function of the Centre. This will ensure multidisciplinary team working”.

The NHS Cancer Plan (2000) followed on and pledged that, from 2001, every patient would be reviewed by MDTs:

“A consistent theme in the Improving Outcomes guidance is that cancer services are best provided by teams of clinicians – doctors, nurses, radiographers and other specialists – who work together effectively. Team working brings together staff with the necessary knowledge, skills and experience to ensure high quality diagnosis, treatment and care. It also improves the co-ordination and continuity of care for patients.”

MDTs were not just for cancer. In 2019, the NHS Long Term Plan advocated them for nine other specialties, including coronary heart disease, frailty and primary and community care.

MDTs overwhelmed by demand

Even before the Long Term Plan, however, it was clear that MDTs were not working as originally intended. That remains the case. Above all, they are drowning in demand. Taking cancer as an example, while the intention to review every patient in an MDT is good, most cases don’t need to be there. Cases are either benign (and don’t need to be discussed) or are a cancer (in which case the treatment/management plan is largely predetermined based on type and stage). Discussion is only needed for the much smaller proportion of cases that are atypical, undetermined or complicated by other factors such as associated diseases that could impact treatment.

As a result, the quality of discussion that occurs can be very limited given the huge volumes of patients that are crammed into meetings. Cancer Research UK made this point in its 2017 report Meeting Patients’ Needs, based on a review of cancer MDTs:

“The mean length of the 624 patient discussions observed in this study was 3.2 minutes, and over half of MDT discussions were less than two minutes long. Meetings could last up to five hours. It is difficult to imagine that this method of working produces the same quality of discussion for all patients, or that there is always enough time for full discussion of patients with particularly complex cases.”

In my experience, quality of discussion can also be diminished by problems of legacy IT. Often, the clinical information for a patient is incomplete. Results are often missing which makes assessment impossible. If a patient cannot be assessed then they are bumped to the next meeting which builds in further artificial delay into their care. When teams are pulling information in from multiple systems for multiple patients, it is not uncommon for the wrong scans to be pulled up or for the discussion to be associated with the wrong patient. This is a major safety concern and is made worse by the number of patients and the number of systems that information needs to be retrieved from.

Lastly there are real problems with limiting discussion to the MDT meeting itself. It means that clinicians discuss their opinion of a case much later (even over a week) than their first review. The requirement for fixed slots builds in unnecessary and artificial delay into the patient journey. Not all clinical participants are needed for every case and so there is often wasted time for individuals. Sometimes key individuals get called away because of an emergency, making decision-making impossible and meaning that many patients get pushed to the next meeting.

NHS England did recognise many of these problems and published guidance for cancer alliances on streamlining MDT meetings in 2020. The issues however have persisted and have been exacerbated by the rush of returning demand following the pandemic. In 2023, the Greater Manchester Cancer MDT Reform Project concluded:

“Health services have changed significantly since the introduction of MDTMs [multidisciplinary team meetings] in 1995. These meetings have come under increasing pressure due to significant increases in caseload [and] a change in case-mix including a high number of patients with comorbidities due to an ageing population … There are also issues relating to consistent, reliable information technology, data collection and infrastructure such as videoconferencing. The necessary information regarding the patient and their clinical diagnosis/diagnostic results is not always available to the MDT resulting in a delay in decision-making.”

Breaking free

Technology such as Bleepa breaks free from the need to wait for an MDT to discuss a case. (Bleepa is the only system that allows clinicians to communicate instantly and securely via mobile devices, including the sharing of diagnostic-quality images as well as historical records and blood test results. It is in use in hospital trusts in Greater Manchester, Sussex and Berkshire and is being piloted by NHS England in the Bucks Oxon and Berkshire West ICB to improve digital diagnostic pathways).

Using Bleepa, clinicians can give opinions at the same time as they are reporting studies. The relevant diagnostician can assign the patient to the right clinical group (i.e. benign, cancer, needs discussion) at the time of reporting, greatly reducing the proportion of cases that need to go forward for discussion by the wider MDT. Patients can be added to the “needs discussion” by other stakeholders later in the pathways if needed. This all helps with caseflow management.

The asynchronous approach removes the traditional delays of waiting for an MDT slot. Discussion (via Bleepa chat messages) starts as soon as results are available and the patient has been allocated into the appropriate stream, reducing wait times considerably, allowing organisations to hit the Faster Diagnosis Standard. Specialists can contribute on a rolling basis, based on their availability around other pressing clinical work. This releases sessional time that can be used for other work such as outpatients or interventional work.

Being able to contribute directly to an MDT discussion at the time of reporting greatly reduces administrative work in maintaining separate MDT notes for use at a later date. It also means that any ensuing questions from colleagues occur typically while the case is fresh in mind, improving the accuracy of response and turnaround times.

Bleepa also provides a dashboard view, giving clinicians and coordinators the ability to track their patients and to manage their workflows. Often clinicians do not get to see this level of overview and I believe it helps to see that patients are progressing rather than just appearing and disappearing from your lists.

Being able to collaborate effectively remotely is a game changer. With videoconferencing programs clinicians are still stuck to a desk somewhere; with chat messages they can participate on a phone from anywhere. This is particularly important for younger clinicians and may even be a good tool for staff retention.

To give a personal word as a radiologist: this new technology allows radiology to return to what it should be i.e. a service that adds benefit to frontline colleagues and answers specific clinical questions. Radiologists will still write a formal report on a case but a Bleepa chat message allows them to succinctly answer the key clinical question being asked, which arguably adds more value to clinical colleagues than a long report that they need to digest. Bleepa takes us back to the root of the specialty and puts the “clinical” back in our title “clinical radiologist”.

Conclusion

At its board meeting on 16 May, NHS England reviewed the evidence for a fall in NHS productivity since the pandemic. The board pointed to an increase in complexity and acuity amongst patients admitted to hospital and the effects of (in their words) staff burnout and lower engagement. It rightly said that the situation, while highly challenging, is not irrevocable. It wanted to tackle the problem at source by moving towards “a healthy, motivated and engaged workforce” which uses “21st century technology”.

Changes to the way that multidisciplinary teams work are a great example of what can be done. Modern, secure chat-based technology means that teams don’t have to wait for lengthy meetings to consult on cases. Clinicians can experience the satisfaction of using their professional expertise and engaging with colleagues immediately and on cases that require their attention.

It would be fitting to mark the 30th anniversary of the Calman-Hine Report, in 2025, with this new model of MDT, delivering on the vision of joined-up health teams pooling their experience to put the patient first.

For more information on Bleepa, contact us here.

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