Multidisciplinary Team Working
in Head & Neck Cancer
Leeds Head & Neck Cancer Team
[Leeds Teaching Hospitals NHS Trust/
University of Leeds, Mid-Yorkshire NHS Trust
and Calderdale NHS Trust]
The Head & Neck Cancer Team, based at Cookridge Hospital, Leeds is
based on a network, using a ‘hub and spoke’ approach. As well as Leeds
based staff, an active partnership has been established with the Mid Yorkshire
Trust and Huddersfield. The team assesses 250 new patients per year.
All specialities are represented: surgical: ENT, maxillofacial and plastic
surgery; medical: clinical and medical oncology; specialist head and neck
radiologists and pathologists and representatives of disciplines important to
patient care: Macmillan Nurses, dieticians, Speech & Language Therapists
and dentists play an active part. Nursing roles have been developed to assist
the provision of patient information. Additional psycholological support for
patients is available through the Psycho-Oncology team based at the Leeds
Teaching Hospitals Trust. The recent appointment of a Clinic Co-ordinator has
greatly assisted communication within a large clinical team.
Through an active programme of audit and research, linked to the University
of Leeds, the team seeks ways to improve the patient’s experience.
Strategy A: Connect up the patient journey
We have an operational policy for the MDT. Central to adherence to that
policy has been the appointment of the clinic co-ordinator. She ensures that
all relevant material is available to the MDT and that specific clinicians will be
available should their expertise be required.
Because of the size and complexity of the network, this post is essential to
communication between members of the team, based on the patient’s need.
MDT decisions are underpinned by treatment and surgical guidelines. These
agreements allow for effective cross cover and team working. The active
participation of Pathologists and Radiologists ensures that the MDT considers
all patients with a diagnosis of H&N cancer.
Strategy B: Develop the team around the patient journey
Head & neck cancer is heterogenous in the ways that it affects the patient,
and treatment planning at individual level is important. The presence of
clinicians from all relevant disciplines is key to informed decision making.
The team is fortunate to have the presence of specialist radiologists and
pathologists. At each weekly MDT meeting, all relevant results are presented,
scans viewed and interpreted, biopsy and resection reports reviewed, thus
ensuring the best possible evidence for an informed process.
The meeting is held immediately before the clinic, combining the decision
making and clinical episodes and ensuring that the patient journey is central
to the discussion. Because of the morbidity associated with the therapy of
head & neck cancer, once the treatment options have been outlined, patients
are seen by McMillan Nurses, dieticians, Speech & Language Therapists and
dentist as needed to ensure that they understand not only the effects of their
treatment but also those measures that can be undertaken to minimise
morbidity.
The continued development of the team by committed individuals has ensured
that the patient’s needs are central to the activity of the team.
Strategy C: Make patient & carer experience of care central to
every stage of the journey
The team has increased in size and complexity as a result of a commitment to
network effectively. All clinicians bring their cases for consultation and/or
discussion. At the MDT meeting, the optimal management is considered and
the relevant team members subsequently discuss the options with the patient
and their carers.
All patients have the relevant medical, social and cancer related issues
discussed and clinicians work in an integrated fashion, such that each makes
the appropriate contribution to the care of each patient. Interdisciplinary
management is actively supported, using the expertise of each team member
in the most appropriate and effective way.
We have an active programme to ensure that all patients and carers receive
good information about their disease and its treatment, using nationally and
locally produced material.
The use of regular audit, patient satisfaction surveys and an active research
programme based on clinical effectiveness and quality of life initiatives ensure
that patient and carer views are actively sought to improve the patient and
care experience.
Where necessary, we have developed close links with other MDTs, especially
in thyroid cancer where cross MDT management of patients can occur on a
regular basis.
Strategy D: Ensure capacity to meet patient needs
The main risk is that the multidisciplinary clinic exceeds capacity. This has
been addressed by a strict policy that patients are returned to the care and
continued surveillance of individual clinicians. The network approach ensures
that they continue to have access to support through local teams.
All members of the team and primary care doctors can refer patients back for
consideration by the MDT should they have concerns.
Within the control of the team, every effort is made to reach recommended
standards and a recent [Jan 04] internal peer assessment against Cancer
Centre Standards confirmed our success.
Challenges include the provision of care we are unable to offer, usually
because services are stretched to and sometimes beyond capacity. Others
cannot be offered, especially access to continuing dental care and
rehabilitation. Robust business cases have been prepared and it is frustrating
for the team when investment does not match demonstrated need. The
network is effective in providing the best recommendations for patient care but
this has still to be matched by distribution of resources in recognition of the
clustering of the most dependant patients in a single Trust. This needs to be
matched by provision of local resource so that care is not diminished when
patients return to their local units. The co-operation of all Trusts in supporting
the network and encouraging their staff to be part of it has and continues to be
a key part of the success of the team. Some members hold a contract which
allows them to take an active part in treatment of their patients in the Centre,
giving the best combination of centrally and locally based care.
Some aspects lie outside our control: provision of ITU beds and modern
radiotherapy equipment being important areas which need investment and, in
common with many units, our data collection is a matter for individual
enthusiasm and commitment rather than central investment and support.
Summary
Head & neck cancer presents particular and considerable challenges because
of the nature of the disease and the multiplicity of specialities involved in its
management.
Through networking, co-operation and the enthusiasm and commitment of all
staff, we have been able to form a coherent and responsive network,
combining the benefits of centralisation with locally based care and follow up.
Our links with the University allow an active research and development
programme.
Multidisciplinary Team Members:
Leeds Teaching Hospital NHS Trust/University of Leeds:
Lead Clinician: Dr Catherine Coyle (Clinical Oncologist)
Clinical Oncologists: Dr Dan Ash, Dr Mehmet Sen
Medical Oncologist: Dr Galina Velikova [Cancer Research UK]
ENT Surgeons: Mr Jamie Woodhead, Mr Zvoru Makura
Maxillofacial Surgeons: Mr TK Ong, Mrs Sheila Fisher [University of Leeds]
Plastic Surgeon: Mr Mark Liddington
Dentist: Mr Alastair Speirs
Radiologists: Dr Brendan Carey, Miss Fiona Carmichael
Pathologists: Prof. Ken MacLennan, Dr Alec High, Prof. Bill Hume
Macmillan Nurse: Ms Tricia Feber
Speech and Language Therapist: Ms Maria Harvey
Dietician: Ms Sarah Cameron
Clinic Co-ordinator: Mrs Pauline Coghill
Mid-Yorkshire NHS Trust:
ENT Surgeon: Mrs Helen Cruikshank
Maxillofacial Surgeon: Mr David Mitchell [active member Leeds surgical
team], Mr Kelvin Mizen
Radiologist: Dr Nick Spencer
Macmillan Nurse: Ms Julie Hoole
Calderdale:
ENT Surgeon: Mr Dominic Martin-Hirsch