The development of multidisciplinary cancer care in Britains National Health Service (NHS) is being held back by lack of leadership, despite evidence that such coordination might improve outcomes and reduce the length of hospital stays or need for readmission, a new report concluded.
Multidisciplinary cancer care is seen in Britain as a means of promoting communication and effective care and of checking that individual consultants are following accepted guidelines and do not work in dangerous isolation. There is concern in Britain about variations in surgical practice and radiotherapy regimes.
Based on one of the largest-ever surveys of cancer care in the United Kingdom, the report was jointly prepared by the governments Audit Commission and the recently formed Commission for Health Improvement. The survey included 60 NHS trusts or health care providers and nine cancer networks. These networks are responsible for coordinating the work of the trusts and working closely with the voluntary sector and so called "patient user groups."
The report, NHS Cancer Care in England and Wales, concluded: "There is a need for clear lines of accountability, including who is responsible for leading the team. Time may need to be spent on group dynamics, including training in working as a team."
But many specialists see multidisciplinary cancer care as a logical extension of the long-established British tradition of case conferences, in which the chief of a medical or surgical department discusses interesting cases with students, trainees, or junior doctors. However, there one major difference. The old authoritarian tradition has been eroded by a new brand of formality encompassing a large team of up to 20 doctors, nurses, social workers, pharmacists, and dieticians, in addition to the patients themselves. But the new order is still evolving, without any clear consensus of the best multidisciplinary model.
This reflects a radical shift in opinion about the traditional, authoritarian power base of the consultant. "The old concept of a single consultant being in total charge of a patient and making all the decisions, which in his or her view was the only view, is no longer tenable," said Alan Axford, M.B., consultant physician and medical director of the Bronglais Hospital, Aberystwyth, in Wales.
"In our multidisciplinary cancer care teams, youll find as many nurses as doctorssupport nurses, palliative care nurses, specialist nursestheyre all there and theyll all express their views. We get multidisciplinary input at all levels, hopefully resulting in more holistic care."
A pioneer in a multidisciplinary telemedicine program linking Aberystwyths remote hospital to a large cancer center in Swansea 70 miles away, Axford said he believes that most U.K. cancer specialists are now committed to the multidisciplinary cause.
But the survey revealed that multidisciplinary cancer care in the United Kingdom is "patchy" and nonexistent in many hospitals. A case study revealed that at one trust, only four of the eight colorectal surgeons went to multidisciplinary cancer care meetings. A similar pattern emerged within another trust that included one hospital with no multidisciplinary colorectal care at all.
The survey did not establish why some surgeons within the same trusts supported multidisciplinary cancer care meetings while others did not.
Calling on hospitals and trusts to "provide more help to bring about necessary changes in the organizations of all aspects of cancer services," the report pointed out that almost all trusts have appointed lead clinicians to coordinate cancer care. But these leads have no formal powers to challenge other clinicians. Their influence depends on gaining the respect of their colleagues. If any real improvements are to be made to patient care, the report added, they will need to be "developed as clinical leaders and given the authority to make sure that protocols and standards are followed."
Dick Waite, Ph.D., senior project manager at the Audit Commission, believes that the biggest problem in multidisciplinary cancer care is often not so much a traditional power struggle as it is a question of who is best suited to take control. It is significant, he explained, that the number of trusts/hospitals reporting regular multidisciplinary cancer care meetings varied from about 90% for breast cancer to less than 30% for endocrine cancer.
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In contrast, Waite continued, "if youre a urologist, you may be treating a lot of patients, as well as those with cancer, which means that cancer wont be so all-consuming."
This can create a communication vacuum. As treatment processes become more complicated and the number of people involved increases, clear communication between professionals and patients becomes increasingly important.
The report added: "All professionals should understand their role in relation to that of others and should then make sure that the care plan, taken as a whole, deals with all of the patients needs. ... Moreover, there can be confusion between the diagnosing surgeon, oncologists, nurses, and primary care staff about who should be assessing whether patients having chemotherapy or radiotherapy can cope at home or not."
Having multidisciplinary teams is not a panacea. Although most teams meet on a weekly basis, in some areas and for some types of cancer, they meet only monthly or less. Some specialists, such as pathologists and radiologists work with several different types of cancer, and/or in different areas, making the time commitment especially difficult.
The report recommends telemedicine links to larger centers like the program developed at the Bronglais Hospital to unite team members in different places.
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