Intelligence
National Cancer Action Team
Part of the National Cancer Programme
National Cancer Peer Review Programme
Manual for Cancer Services:
Skin Measures
Version 2.1
DH INFORMATION READER BOX
Estates
Commissioning
IM & T
Finance
Social Care / Partnership W orking
Policy
HR / W orkforce
Management
Planning /
Clinical
Document Purpose
Best Practice Guidance
Gateway Reference
10790
Title
Skin Specific Measures
Author
National Cancer Peer Review -National Cancer Action Team
Publication Date
April 2011
Target Audience
PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs , SHA Cancer
Leads
Circulation List
Cancer Network Medical Directors, Cancer Network Directors, Cancer
Network Lead Nurses, Cancer Action Team, DH Policy Officials, NHS
Improvement managers, Royal Colleges, Members of the National Cancer
Peer Review Steering Group, National Cancer Peer Review User Group,
Voluntary Sector
Description
Following a three month consultation period, this is the final version of the
Skin measures for inclusion within the Manual for Cancer Services. The
measures can also be found on the CQUINS website at www.cquins.nhs.uk
Cross Ref
Superseded Docs
Action Required
Policy
Manual for Cancer Services
0
N/A
Timing
N/A
Contact Details
Zara Gross
Project Assistant National Cancer Peer Review,
National Cancer Action Team
18th Floor, Portland House
Bressenden Place
London, SW1E 5RS
0
For Recipient's Use
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
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SKIN SPECIFIC MEASURES
Contents
11-1A-2j - SKIN SPECIFIC NETWORK BOARD MEASURES
Measure
Number
Measure
11-1A-201j
Agreed Named Members and Terms of Reference of NSSG
11-1A-202j
Agreed Network IOG Implementation Summary
11-1A-203j
This measure has been withdrawn
11-1A-204j
Network Configuration of MDTs
11-1A-205j
This measure has been withdrawn
11-1A-206j
Network Agreed Referral Patterns Between Named PCTs and LSMDTs
11-1A-207j
Network Agreed Referral Guidelines Between Teams
11-1A-208j
Agreed Network Referral Guidelines to Named Supra-network T-cell
Lymphoma MDT for TSEBT
11-1A-209j
Agreed Network Guidelines for Referral for Photopheresis
11-1A-210j
Agreed Network Distribution of Clinics for Immunocompromised
Patients with Skin Cancer
11-1A-211j
Arrangements for Head and Neck Skin Cancer
11-1A-212j
Arrangements for Anal and Perianal Skin Cancer
11-1A-213j
Arrangements for Skin Cancer of External Female Genitalia
11-1A-214j
Arrangements for Skin Cancer of External Male Genitalia
11-1A-215j
Arrangements with Haemato-oncology Teams for Lymphoma Involving
Skin
11-1A-216j
Arrangements with Sarcoma MDTs for Sarcoma Involving Skin
SKIN SPECIFIC MEASURES
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11-1C-1j - FUNCTIONS OF NETWORK SITE SPECIFIC GROUPS (NSSGs)
Measure
Number
Measure
11-1C-101j
NSSG Meeting
11-1C-102j
Annual Review, Work Programme and Annual Report
11-1C-103j
Agreed Minimum Dataset
11-1C-104j
Network Audit
11-1C-105j
Discussion of Clinical Trials
11-1C-106j
Network Agreed Three Year Service Development Plan
11-1C-107j
Network Agreed Clinical Guidelines
11-1C-108j
Network Agreed Imaging Guidelines for Diagnosis and Assessment
11-1C-109j
Network Agreed Pathology Guidelines for Diagnosis and Assessment
11-1C-110j
Network Agreed Primary Care Referral Guidelines
11-1C-111j
NSSG Designated Hospital Practitioners for Mohs Surgery
11-1C-112j
This measure has been withdrawn
11-1C-113j
This measure has been withdrawn
11-1C-114j
Chemotherapy Treatment Algorithms
11-1C-115j
The TYACN Pathway for Initial Management
11-1C-116j
The TYA Pathway for Follow Up on Completion of First Line Treatment
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11-1D-1j - FUNCTIONS OF THE LOCALITY GROUP
Measure
Number
Measure
11-1D-101j
Provision of Clinics for Immunocompromised Patients with Skin Cancer
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11-2J-1 - SKIN CANCER MULTIDISCIPLINARY TEAM (MDT)
Measure
Number
Measure
11-2J-101
Lead Clinician and Core Team Membership
11-2J-102
Named Clinical Oncologist
11-2J-103
Level 2 Practitioners for Psychological Support
11-2J-104
Support for Level 2 Practitioners
11-2J-105
Team Attendance at NSSG Meetings
11-2J-106
MDT Meeting
11-2J-107
MDT Agreed Cover Arrangements for Core Members
11-2J-108
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-109
Annual Meeting to Discuss Operational Policy
11-2J-110
Bi-annual Educational/Audit Meetings
11-2J-111
Policy for All New Patients Specified as Level 4, 5 or 6 Care to be
Reviewed by MDT
11-2J-112
Policy for Communication of Diagnosis to GPs
11-2J-113
Operational Policy for Named Key Worker
11-2J-114
Core Histopathology Member Taking Part in Histopathology EQA
11-2J-115
Core Nurse Members Completed Specialist Study
11-2J-116
Agreed Responsibilities for Core Nurse Members
11-2J-117
Attendance at National Advanced Communications Skills Training
Programme
11-2J-118
Extended Membership of MDT
11-2J-119
This measure has been withdrawn
11-2J-120
This measure has been withdrawn
11-2J-121
This measure has been withdrawn
11-2J-122
Patient Permanent Consultation Record
11-2J-123
Patient Experience Exercise
11-2J-124
Provision of Written Patient Information
11-2J-125
Agree and Record Individual Patient Treatment Plans
11-2J-126
Network Referral Guidelines Between Named Teams
11-2J-127
MDT Agreement to Clinical Guidelines for the Management of Skin
Cancer
11-2J-128
MDT Agreement to Imaging Guidelines
11-2J-129
MDT Agreement to Pathology Guidelines
11-2J-130
Agreed Collection of Minimum Dataset
11-2J-131
Network Audit
11-2J-132
Discussion of Clinical Trials
11-2J-133
This measure has been withdrawn
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Measure
Number
Measure
11-2J-134
This measure has been withdrawn
11-2J-135
Joint Treatment Planning for TYAs
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11-2J-2 - SPECIALIST SKIN MULTIDISCIPLINARY TEAM (SSMDT)
Measure
Number
Measure
11-2J-201
Lead Clinician and Core Team Membership
11-2J-202
Level 2 Practitioners for Psychological Support
11-2J-203
Support for Level 2 Practitioners
11-2J-204
Team Attendance at NSSG Meetings
11-2J-205
MDT Meeting
11-2J-206
MDT Agreed Cover Arrangements for Core Members
11-2J-207
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-208
Annual Meeting to Discuss Operational Policy
11-2J-209
Bi-annual Educational/Audit Meetings
11-2J-210
Policy for all New Patients Specified as Level 4, 5 or 6 Care to be
Reviewed by MDT
11-2J-211
Policy for Communication of Diagnosis to GPs
11-2J-212
Specific Procedures Carried Out in Same Named Hospital
11-2J-213
Individual Surgical Member Inguinal or Axillary Dissections Workload
11-2J-214
Operational Policy for Named Key Worker
11-2J-215
Core Histopathology Members Taking Part in the National Specialist
Dermatopathology EQA
11-2J-216
Policy for Discussion of Cutaneous Lymphoma Cases Referred for
Potential Photopheresis
11-2J-217
Core Nurse Members Completed Specialist Study
11-2J-218
Agreed Responsibilities for Core Nurse Members
11-2J-219
Attendance at National Advanced Communications Skills Training
Programme
11-2J-220
Extended Membership of MDT
11-2J-221
This measure has been withdrawn
11-2J-222
This measure has been withdrawn
11-2J-223
This measure has been withdrawn
11-2J-224
Patient Permanent Consultation Record
11-2J-225
Patient Experience Exercise
11-2J-226
Provision of Written Patient Information
11-2J-227
Agree and Record Individual Patient Treatment Plans
11-2J-228
MDT/Network Referral Guidelines Between Named Teams
11-2J-229
MDT Agreement to Clinical Guidelines for the Management of Skin
Cancer
11-2J-230
MDT Agreement to Imaging Guidelines
11-2J-231
MDT Agreement to Pathology Guidelines
11-2J-232
Agreed Collection of Minimum Dataset
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Measure
Number
Measure
11-2J-233
Network Audit
11-2J-234
Discussion of Clinical Trials
11-2J-235
This measure has been withdrawn
11-2J-236
This measure has been withdrawn
11-2J-237
Joint Treatment Planning for TYAs
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11-2J-3 - MELANOMA MULTIDISCIPLINARY TEAM (MMDT)
Measure
Number
Measure
11-2J-301
Lead Clinician and Core Team Membership
11-2J-302
Level 2 Practitioners for Psychological Support
11-2J-303
Support for Level 2 Practitioners
11-2J-304
Team Attendance at NSSG Meetings
11-2J-305
MDT Meeting
11-2J-306
MDT Agreed Cover Arrangements for Core Members
11-2J-307
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-308
Annual Meeting to Discuss Operational Policy
11-2J-309
Specific Procedures Carried Out in Same Named Hospital
11-2J-310
Individual Surgical Member Inguinal or Axillary Dissections Workload
11-2J-311
Operational Policy for Named Key Worker
11-2J-312
Core Histopathology Members Taking Part in the National Specialist
Dermatopathology EQA
11-2J-313
Core Nurse Members Completed Specialist Study
11-2J-314
Agreed Responsibilities for Core Nurse Members
11-2J-315
Attendance at National Advanced Communications Skills Training
Programme
11-2J-316
Extended Membership of MDT
11-2J-317
Patient Permanent Consultation Record
11-2J-318
Patient Experience Exercise
11-2J-319
Provision of Written Patient Information
11-2J-320
Agree and Record Individual Patient Treatment Plans
11-2J-321
MDT Agreement to Referral Guidelines Between Named Teams
11-2J-322
MDT Agreement to Agreed Clinical Guidelines for the Management of
Malignant Melanoma
11-2J-323
MDT Agreement to Agreed Imaging Guidelines
11-2J-324
MDT Agreement to Agreed Pathology Guidelines
11-2J-325
Agreed Collection of Minimum Dataset
11-2J-326
Network Audit
11-2J-327
Discussion of Clinical Trials
11-2J-328
Joint Treatment Planning for TYAs
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11-2J-4 - THE SUPRANETWORK T-CELL LYMPHOMA MULTIDISCIPLINARY TEAM FOR
TOTAL SURFACE ELECTRON BEAM THERAPY
Measure
Number
Measure
11-2J-401
Lead Clinician and Core Team Membership
11-2J-402
All Consultant Oncologists Responsible for Performing TSEBT Should
be Core Members of the Supranetwork Team
11-2J-403
All Treatments with TSEBT Should be Delivered in the Same
Department
11-2J-404
MDT Meeting
11-2J-405
MDT Agreed Cover Arrangements for Core Member
11-2J-406
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-407
Agree and Record Individual Patient Treatment Plans
11-2J-408
Provision of Written Patient Information
11-2J-409
Discussion of Clinical Trials
11-2J-410
Joint Treatment Planning for TYAs
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Introduction
1.1 Aim of the Manual for Cancer Services
The Manual for Cancer Services is an integral part of Improving Outcomes: A Strategy for Cancer and aligns
with the aims of the Coalition Government: to deliver health outcomes that are among the best in the world.
The Manual will support the National Cancer Peer Review quality assurance programme for cancer services
and enable quality improvement both in terms of clinical and patient outcomes.
The National Cancer Peer Review Programme, which is led by the National Cancer Action Team and includes
expert clinical and patient/carer representation, provides important information about the quality of clinical
teams and a national benchmark of cancer services across the country.
National quality standards/measures for cancer services were first published in 2001 and were updated in
2004 and 2008. The range of measures has subsequently been extended to cover virtually all cancer-sites
and cross cutting cancer services (e.g. chemotherapy, radiotherapy). It is intended that the National Cancer
Intelligence Network (NCIN) clinical reference groups will review the measures within the manual for cancer
services annually to ensure they are clinically relevant and it is intended that the measures will underpin the
NICE Quality Standards relating to cancer.
An independent evaluation of the National Cancer Peer Review Programme demonstrated strong support for
the programme to continue, subject to reducing the burden of peer review and putting greater emphasis on
outputs and outcomes as and when data becomes available.
In response to this the number of measures has been reduced by over one third in 2008 and more recently by
a further 10%. In addition "Clinical Lines of Enquiry" (CLE) have been introduced, based on outputs/outcomes
to support the Manual for Cancer Services. The revised process for peer review will be implemented in April
2011 but the measures contained within this manual will remain an integral part of the review process.
Compliance with the manual has not been centrally imposed. Although the NHS is not mandated to adhere to
the measures in the Manual for Cancer Services, it is currently used by the National Cancer Peer Review
Programme as part of their local assessment of cancer services and to provide a ready specification for
commissioning of cancer services within a given locality.
1.2 Background and Context
Substantial progress has been made in cancer in the last decade, particularly since the publication of the NHS
Cancer Plan in 2000. However, major challenges remain and in January 2011 Improving Outcomes: A
Strategy for Cancer was published.
The strategy sets out how the future direction for cancer will be aligned with Equity and Excellence: Liberating
the NHS in addition to meeting its stated aim to saving an additional 5,000 lives every year by 2014/15, aiming
to narrow the inequalities gap at the same time.
The strategy acknowledges the importance of comprehensive information about cancer services for individual
members of the public, cancer patients and their carers, healthcare professionals and commissioners.
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1.3 Measures within the National Cancer Peer Review Manual
The peer review is changing its emphasis to focus on both clinical and patient outcomes. In order to achieve
this, 'Clinical Lines of Enquiry' have been introduced and it is intended these outcome indicators will form part
of the measures along with a reduced number of structure and process measures.
The development of cancer measures is an ongoing process in order to:
reflect new NICE Quality Standards and clinical guidelines and revisions to existing NICE guidance;
allow greater influence by users of cancer services and their carers;
allow greater influence by clinicians;
take account of possible modifications to measures following peer review visits;
ensure the scope of measures encompasses the broader implementation of the Improving Outcomes: A
Strategy for Cancer;
• reflect new initiatives such as lapco, information prescriptions.
•
•
•
•
•
The relationship between the NICE Improving Outcomes Guidance and Quality Standards and the Manual for
Cancer Services is explained in more detail in appendix A.
1.4 Reviewing the Measures
The National Cancer Peer Review (NCPR) Programme aims to improve care for people with cancer and their
families by:
•
•
•
•
•
•
ensuring services are as safe as possible;
improving the quality and effectiveness of care;
improving the patient and carer experience;
undertaking independent, fair reviews of services;
providing development and learning for all involved;
encouraging the dissemination of good practice.
The benefits of peer review have been found to include the following:
• provision of disease specific information across the country together with information about individual
teams which has been externally validated;
• provision of a catalyst for change and service improvement;
• identification and resolution of immediate risks to patients and/or staff;
• engagement of a substantial number of front line clinicians in reviews;
• rapid sharing of learning between clinicians, as well as a better understanding of the key
recommendations in the NICE guidance.
The NCPR programme has been keen to take the opportunity to reduce the burden on the NHS in line with
the efficiency gains asked of all NHS organisations. The revised methodology will reduce the burden on the
service without substantially impacting on the quality assurance process. It is envisaged that these changes
will reduce the burden on the service by almost 50% from the previous process.
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Appendix A
Interpretation of the National Manual for Cancer Services
1.1 Guidance Compared to Cancer Measures
The NICE Improving Outcomes Guidance is exactly what it says - guidance in general and indeed is excellent
for this purpose. Guidance involves giving advice and recommendations on how things should be done now,
in the future and sometimes on how things should have been done for sometime already. It may involve
describing in effect the "perfect" service, using phrases like "the best possible", "to all patients at all times",
etc. It may involve all-inclusive and far-ranging objectives and aspirations involving many agencies in long,
interlinked chains of events and tasks which all have to be fulfilled before the desired outcome of the guidance
is achieved. A particular person's accountability for each task is often not stated.
It may use influential and important ideas and models, which are however complex or not precisely definable,
such as "network-wide patient care pathways" or "culturally-sensitive information". It always contains useful
and necessary value judgements which use words like "sufficient", "appropriate", "robust" and
"comprehensive", but it often has to leave unanswered the key question - what exactly is it which makes the
issue under examination "sufficient", "appropriate", "robust" and "comprehensive" or not? It uses concepts
which, although crucial, may not be measurable. It ranges widely from things which everybody gets right as a
matter of course already through to principles which, if taken literally, nobody would comply with ever.
All these features, although they may sound unhelpful as described above, are present in all guidance
documents and are part of the necessary and accepted style of guidance writing. Without this underlying type
of mindset, guidance would not inspire, lead, motivate or guide and would probably be almost unreadable.
The Manual for Cancer Services has to take a different approach. It is written for and only for the specific
purpose of being used to assess a service against it, to aid self assessment and team development (a) by a
peer review visit; (b) on a specific occasion; (c) a visit which has to be fair compared to visits to other services
elsewhere and (d) to past and future visits to the same service. Therefore, the measures have to:
• be objective - with as little room as possible for arguments between assessors and assessed; and
between different teams of assessors;
• be measurable - and at least capable of definitely being complied with or not;
• be specific - not addressing several issues at once or long, linked chains of tasks all being done by
different agencies;
• be verifiable - by evidence produced for the visit; state who exactly is responsible for what - or nobody
may take responsibility for anything;
• sometimes deal with the implications of the guidance - which may not have been explicitly stated but
which are essential for anything to actually happen;
• be discriminating - it's no use spending time and money on assessing something which everybody gets
right already;
• be achievable - it's no use committing everybody to permanent and automatic failure because of the way
something is worded;
• be clear and unambiguous - the words will be taken to mean exactly what they appear to say, and
therefore they have to say exactly what we mean and nothing else;
• pick out and address the most important issues - the peer review process is limited in its scope;
• be developmental - encourage continuous quality improvement and not produce destructive competition
or a sense of failure;
• be sensibly and fairly related to previous standards - in order to be developmental -not just arbitrarily
moving the goal posts.
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All this results in the rather esoteric style of the manual. Please judge the measures on their merits in the light
of the above and not in comparison to the guidance.
1.2 "The Responsibility for Assessment Purposes"
This refers to the fact that someone, or some group, is always held nominally responsible for compliance with
each one of the quality measures. This has to be specified or, in terms of organising the peer review and
collecting the results, it would be unclear who was being held as compliant or non-compliant or who the
results could be attributed to. Where it is unclear who has responsibility there tends to be inertia. This
attribution of responsibility does not necessarily commit a given person to actually carrying out a given task this can be delegated according to local discretion, unless it is clear that a given task really is limited to
ascertain group.
1.3 "Agreement"
Where agreement to guidelines, policies etc. is required, this should be stated clearly on the cover sheet of
the three key documents including date and version. Similarly, evidence of guidelines, policies etc requires
written evidence unless otherwise specified. The agreement by a person representing a group or team (chair
or lead etc) implies that their agreement is not personal but that they are representing the consensus opinion
of that group.
1.4 Confirmation of Compliance
Compliance against certain measures will be the subject of spot checks or further enquiries by peer reviewers
when a peer review visit is under taken. When self assessing against these measures a statement of
confirmation of compliance contained within the relevant key evidence document will be sufficient.
1.5 "Quality" Aspects of Cancer Service Delivery
Many of the measures expect that policies, procedures, job descriptions and other documents will be in place.
In reviewing compliance with the measures (for instance measure met or not) during validation, verification
and visits, reviewers will look only for the presence of such documents, unless aspects of the content are
specified in the wording of the measure. Where some aspect of the content is specified then this will be taken
into account in determining compliance. As part of the improvement of cancer services, reviewers may
comment on the content of documents and agreements but this will not affect the determination of
compliance.
Work is ongoing to enable us to subject more of the "quality" aspects of cancer service delivery to objective
measures for future rounds of peer review.
Many reviewers have a legitimate and valuable contribution to make by way of comments on areas which are
a matter of opinion rather than fact or authoritative and evidence based standards. This recognises the
qualitative as well as quantitative approach to reviews. This contribution can be made by way of a textual
report in addition to the objective recording of compliance against the measures. This report is separate from
the review against the measures and is inevitably more subjective and open to debate. However, there are
many ways in which it can add to the overall picture gained from the peer review.
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1.6 Structure of the Measures
Each measure has a three part number, for example 11-1A- 201j.
• The first part indicates the year the measure was first issued, for example 11 is 2011.
• The second part relates to a particular topic see below, for example 1A.
• The third part is made up of a unique measure number in the topic and where relevant a suffix letter
indicating a specific tumour and cross cutting services, for example 201j (see below).
Index of Suffix Letters
a - Generic to all tumour sites
r - Specialist Palliative Care specific
b - Breast specific
s - Chemotherapy specific
c - Lung specific
t - Radiotherapy specific
d - Colorectal specific
u - User Group specific
e - Gynaecology specific
v - Rehabilitation specific
f - UGI specific
w - Complementary Therapy specific
g - Urology specific
x - Psychological Support specific
h - Haematology specific
y - Acute Oncology
i - Head and Neck specific
j - Skin specific
Each network will be made up of several localities/trusts and several NSSGs / cross cutting groups,
each with multiple MDTs and services. These MDTs and services will each need to demonstrate compliance
with the relevant quality measures. A network overview will be developed by bringing together the findings
relating to individual MDTs and services as well as those concerning network organisation and structures.
Manual for Cancer Services On-line
An on-line version of the Manual for Cancer Services has been developed. The on-line version allows
individuals to identify and extract measures by tumour site, organisation type and subject area in a variety of
formats.
The on-line manual can be accessed from the CQuINS web site at http://www.cquins.nhs.uk.
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Skin Cancer Measures
INTRODUCTION
Skin cancer differs fundamentally from other types of cancer in certain aspects which have
determined the content of the 2006 Improving Outcomes Guidance (IOG).
These aspects include:
i. Its very high incidence overall, compared to other types of cancer.
ii. Its extremely wide range of seriousness, from extremely good prognosis to life-threatening.
iii. Its ready visibility and accessibility on the surface, giving opportunities for excision and diagnosis
by practitioners in the community.
IOG Implementation
The specialist commissioning groups (SCGs) are responsible for agreeing the implementation
proposals of the skin cancer 2006 IOG.
Shape of the Service
The IOG either explicitly or by implication, effectively specifies six levels of care, differing in the
degree of specialisation and service consolidation needed. The personnel foreseen as offering these
levels range from any general practitioner, through specifically authorised and trained community
practitioners, local and specialist MDTs to supranetwork MDTs. All this is incorporated into the
Network referral guidelines and Network infrastructure for Skin Cancer, set out in the measures. The
types of case mix and the procedures which make up the different levels and the personnel practising
at each level are given in Table 1.
This revised edition of the skin cancer measures (2011) takes into account the following:
•
•
General revisions and reduction of the number of measures; a process common to a
number of cancer sites.
The revised and updated guidance on the management of skin cancer in the
community, contained in the 2010 update to the NICE IOG on skin cancer, and the
2011 DH Revised guidance on GPwSI dermatology and skin surgery services
Revised guidance on GPwSI dermatology and skin surgery services | GP and
Practice Team Bulletin online
Following discussions, subsequent to the production of the 2006 IOG, it was seen that in some
networks there exist established groups or MDTs specialising only in the treatment of malignant
melanoma. These were not specifically referred to in the IOG. It was not, however, the intention of the
guidance development group that these should necessarily be incorporated into SS MDTs or, if
remaining as ‘stand alone’ MDTs that they should be non compliant with peer review. Therefore, in
order that they are constituted and function at least according to the quality of service expected of all
MDTs, a set of measures for a melanoma MDT (MMDT) has been derived using the principles of the
IOG.
A given cancer network may or may not choose to run a MMDT, but where it does, it should be put
forward for review against the MMDT measures. In that case, the network’s overall practice in relation
to such an MDT is specified at various points in the network and NSSG measures. (Topic 11-1A and
11-1C)
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Table 1 Levels of Care
Care Level
Person or Team
Case mix / Procedure
•
•
•
1
Any general practitioner in the community
2
Community practitioners working to the ‘DES/LES’ model (Level 2a) or the
‘model 1’ service model (level 2b). See guidance below in the section on
skin cancer in the community. (Page 10 of this document).
3
4
LSMDT, hospital staff core team member (May be core member of
SSMDT acting as ‘local’ LSMDT). Without mandatory individual case
review by MDT.
LSMDT, hospital staff core team member(s), with mandatory individual
case review by LSMDT (may be the SSMDT and its core members acting
as ‘local’ LSMDT)
DES/LES list of BCCs. (Level 2a)
Model 1 list of BCCs (level 2b). See guidance below in the section on skin
cancer in the community.
•
•
High risk BCC
SCC
•
•
•
High risk BCC
Recurrent or with +ve excision
SCC
Malignant Melanoma (MM) – new, single primary, adult, non-metastatic, not
for approved trial entry, up to and including stage II a (must fulfil all these
criteria)
Radiotherapy if attendance by clinical oncologist at LSMDT
Lesion where diagnosis is uncertain but may be malignant
Incompatible clinical and histological findings
•
•
•
•
5
SSMDT hospital staff core team member(s) with mandatory individual
case review by SSMDT. (May have been previously reviewed by LSMDT
or rapidly referred without prior review). For some cases – only one
agreed SSMDT, if more than one in the Network.
•
•
•
•
•
•
SKIN SPECIFIC MEASURES
Benign lesions
Actinic Keratoses
Precancerous – SCC in situ/Bowen’s
Other than categories below
Selected BCCs and SCCs needing plastic/reconstructive surgery by
SSMDT core member (as per Network clinical guidelines)
Radiotherapy (as per Network clinical guidelines). If not discussed and
treated by LSMDT clinical oncology core team member
Metastatic SCC on presentation or newly metastatic
MM – stage IIb or more, or <19 years or metastatic on presentation or newly
metastatic or recurrent or for approved trial entry
Any cases for approved trial entry
Any cases for adjuvant therapy (as per Network clinical guidelines)
Histology opinion from SSMDT core pathology team member
GATEWAY No. 10790 - APRIL 2011
18
•
•
•
Mohs surgery
Skin Cancer in immunocompromised patients including organ transplant
recipients
Skin Cancer in genetically predisposed patients including Gorlin’s
Syndrome
Cases to be dealt with by only one agreed SSMDT per Network, if more than one in
the Network:
•
Cutaneous lymphoma
•
Kaposi’s sarcoma
•
Cutaneous sarcoma above superficial fascia. (Below fascia, refer to
sarcoma MDT)in cancers
•
Other rare skin cancers (see appendix 1 in the Skin Cancer IOG pg
128/129.
Notes:
•
Where a network chooses to have a M MDT all cases of MM for level 5 care
from the M MDT’s catchment area should be referred to the M MDT.
•
6
•
•
Supranetwork team. Selected Networks only. Agreed with SCGs.
Clinician responsible for named facilities for photopheresis (very
small numbers of patients). Agreed with SCGs.
SKIN SPECIFIC MEASURES
There should be agreed working arrangements with site specialised MDT’s for
SCC of Head and Neck and Sarcoma and mucosal malignant melanoma.
•
•
GATEWAY No. 10790 - APRIL 2011
T-cell Cutaneous Lymphoma: Total Body Surface Electron Beam Therapy
T-cell cutaneous lymphoma. Photopheresis
19
Notes:
•
The IOG does not name 6 actual ‘levels’ of care but it does describe at least 6 mutually exclusive
levels of specialisation which, for the purposes of service organisation and for peer review are
best dealt with by the ‘levels’ model.
•
Following along a row gives the person or team authorised to deliver a given level of care, this
level being the highest level at which they should function, although they may deliver all lower
levels; then it gives the case mix or procedures which may be delivered at that level of care, it
being the lowest care level at which they should be delivered.
•
Descriptions of the Directed Enhanced Service/Local Enhanced Service (DES/LES) and Model 1
lists of BCCs which make up Level 2 care can be found in the section on skin cancer in the
community. (Page 10 of this document). The types of BCC which make up these lists, are
classified from the point of view of peer review and referral for treatment as ‘low risk’ BCCs. Any
BCCs outside these lists are considered for the purpose of referral for treatment and the purpose
of peer review, as ‘high risk’ BCCs. These lists are specified in clinical terms, here since initial
decisions in primary care, regarding referral for treatment need to be made before histology is
available. There are additional types of BCC, to be added to the high risk category, defined later
in this document, on histological criteria.
•
Level 3 care requires any treatment to be mandatorily under the care of a hospital doctor who is a
core member of the MDT, but without mandatory, formal discussion of the case by the MDT. The
core member may however choose to present a given, particular case in this category for formal
MDT discussion and level 3 cases should be included in the MDT’s audits. Level 4 care requires
not only that any treatment should be mandatorily under the care of the MDT member but that this
should also be discussed in the formal MDT meeting.
Community skin cancer clinicians are defined by the following criteria;
•
•
•
Enrolment on a PCT list of accredited clinicians
Fulfil specific training requirement
Working to specified quality assurance measures
These criteria are contained within a service specification for the Network Community Skin Cancer
Service, agreed with the PCTs.
Local Skin Cancer MDTs (LSMDTs) should meet the following criteria:
•
•
Agreed as part of a named locality in the network
Being the only skin cancer MDT in their hospital
Specialist Skin Cancer MDTs (SSMDTs), in addition to fulfilling the criteria applying to LSMDTs,
should meet the following criteria:
•
•
Serving a catchment population for referral (their own local catchment plus the catchment of
referring LSMDTs) of at least 750,000
Serving as the LS MDT for their local (secondary) catchment population.
Supranetwork MDTs for TSEBT are defined by having their role and catchment population agreed by
the relevant specialist commissioners. It is intended that in most cases, a supranetwork team will
cover more than one Network.
The case numbers associated with photopheresis are extremely small, nationally, and the use of this
treatment for malignancy (erythrodermic cutaneous T-cell lymphoma) is currently limited to 2 centres
in England, with no apparent capacity problems. For this reason, it is not practical, to set mandatory
measures for a full “supranetwork MDT” model to deliver this treatment. Networks are merely
required to agree a referral guideline for this, with the SCGs, naming the facility which they will use.
Melanoma MDTs (MMDTs) should meet the following criteria:
•
•
Listed as part of a named locality of the network
Serving a catchment population for referral of a least 750,000
SKIN SPECIFIC MEASURES
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20
•
•
Taking all referrals of malignant melanoma for level 5 care, from their catchment
population.
In addition, taking all referrals of malignant melanoma for level 4 care from their local
(secondary) catchment population.
The above criteria constitute the minimum scope of a MMDT’s practice for compliance. The network
may choose to agree, via its referral guidelines, a greater scope for the M MDT’s practice, e.g. taking
malignant melanoma for level 4 care and above from the whole of its catchment population or taking
direct referral of pigmented lesions from primary care. This is not subject to review.
It should be understood that in producing measures for the MMDT, it is not intended to encourage the
initiation of large numbers of new MMDTs which add little to the service. The aim was to cater for
teams which add value by consolidating expertise in the use of complex and potentially difficult
treatments in the management of relatively uncommon clinical situations. It is hoped and expected
that in practice, the MMDT would take Level 5 referrals for Malignant Melanoma from much more than
the minimum, 750,000 catchment population.
The interrelationships and referral pathways between community practitioners and the different MDT
types are given in Figure 1.
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
21
Figure 1
See Figure 2
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
22
Management of Skin Cancer in the Community
Note June 2012:
The following section describes the current arrangements for managing skin cancer community
services. It is recognised there are a number of changes taking place with regards to the role of the
PCTs which at the time of issuing these measures remains unclear.
During this transition services are still required to meet the recommendations in the revised and
updated guidance on the management of skin cancer in the community, contained in the 2010 update
to the NICE IOG on skin cancer, and the 2011 DH Revised guidance on GPwSI dermatology and skin
surgery services, however the measures relating to the community skin cancer services have not
been issued. Services will not be reviewed or required to self assess against these for 2012
Figure 2 Acceptable Models for the Management of Skin Cancer in the Community by Surgical
excision or Curettage
Under Community Based
Provider Governance
DES/LES
SKIN SPECIFIC MEASURES
Model 1
Under Acute Trust
Governance
Model 2
GATEWAY No. 10790 - APRIL 2011
Model 3
23
Brief Summary
The service provided under the ‘DES/LES’ contracting system and the Model 1 service are to allow
doctors in the community to diagnose and surgically treat low risk BCCs at two levels of risk, under
two different levels of training/ other requirements. Service Model 2 is to allow trained medical or
nursing practitioners to offer a technical surgical service in the community, for skin cancers diagnosed
and given a treatment plan by other, legitimate referrers. Service Model 3 is to allow for hospital
specialists from MDTs practicing in the community.
1. The Service Provided Under the ‘DES/LES’ Contracting System
Practitioners
GPs acting within the DES or LES NHS statutory framework under the ‘minor surgery’ section.
Governance
PCTs acting according to the DES/LES framework.
Scope of Practice
Excision (or according to clinical judgement, curettage), only of BCCs on the ‘DES/LES’ list,
diagnosed by the practitioners themselves, either de novo or following referral for both diagnosis and
management, from other practitioners. Practitioners acting according to the ‘DES/LES’ service model
should not knowingly excise supposed neoplastic skin lesions of any higher risk than BCCs on the
‘DES/LES’ list.
Requirements of Practitioners
Competencies
•
•
•
Named techniques; local anaesthetics, punch biopsy, shave excision, elliptical excision with
closure, and curettage. (Surgical procedures and related skills as in the 2011 DH guidance, Ref:
Guidance and Competencies for the Provision of Services Using GPs with special interests
[GPwSIs]: Dermatology and Skin Surgery.p13.)
Note: It is intended that this practice should essentially consist of the direct use of excision with
closure, or curettage and cautery on lesions which have been confidently, clinically diagnosed as
within the permitted scope of practice.
Recognition and diagnosis of skin lesions on the ‘DES/LES’ list of BCCs.
Assessment of competence should be by the direct observation of procedural skills (DOPS)
assessment tool in the DH 2011Guidance as above.
CPD
Annual attendance at a skin NSSG ‘educational’ meeting which should include:
• A presentation of network skin cancer audit results. The audit and the presentation should include
a topic involving BCCs, of relevance to practitioners treating them in the community and a
breakdown of individual practitioner performance.
• A four hour CPD session, with an emphasis on skin lesion recognition and the up to date
management of skin cancer (including BCCs) for community practitioners.
Note: It is recognised that content should be appropriate to the practitioners present but it is
strongly recommended that the diagnosis and management of skin cancer and, in
particular, BCCs should be priority subjects for this session.
This CPD session is still a requirement for those practitioners who have been initially trained and
assessed as competent for this level of practice.
Other Requirements
Practitioners should:
• Send all skin samples for histological analysis.
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
2
•
•
•
•
•
Keep records that capture the relevant parts of the national skin cancer minimum dataset.
Follow a histology requesting and reporting protocol, including ‘fail-safe mechanisms, agreed with
1
the relevant pathology laboratory.
2
Provide feedback to the PCT.
Refer skin lesions outside the DES/LES list (and those classified as ‘high risk BCCs’ on
histological grounds, following removal) according to the referral guidelines specified in the skin
cancer measures. Lesions with incomplete margins, otherwise within the DES/LES remit, may be
removed either by the practitioner or a member of the skin MDT, as agreed between them
following discussion. These considerations regarding histologically incomplete excision do not
apply to lesions treated by curettage.
Be registered on a PCT-held list of accredited community skin cancer practitioners.
Numbered notes on the requirements of practitioners:
1) The protocol should include the following specifications:
o If a person has more than one lesion, samples should be sent in separate specimen
pots with separate referral forms.
o All samples should be accompanied by a checklist naming and enumerating the
samples which have been sent.
o By means of the list, any sample identified as not having been received by the
laboratory should be immediately notified to the operating practitioner.
o All results should be cross-checked against the list by the practitioners to ensure that
they have been seen and actioned.
o Reports should classify and report the following as ‘high risk BCCs’ on histological
grounds;
 Those with incomplete excision margins.
 Morpheic, infiltrative, micronodular or basosquamous.
 Perineural invasion below the dermis.
2) The feedback should include:
o Numbers of cases excised and proportion completely excised.
o Pre-excision clinical diagnosis versus post excision histological diagnosis.
Note: The feedback information provides the information necessary for these
community practitioners to be incorporated into the network skin cancer audit.
2. Service Model 1
Practitioners
Either ‘Group 3 GPwSIs’, trained and competent according to the DH Guidance Ref: Guidance and
Competencies for the Provision of Services Using GPs with special interests [GPwSIs]: Dermatology
and Skin Surgery. (2011)
Or a separate class of practitioners ‘GPwSIs in skin lesions’, trained and competent according to the
above DH guidance.
Note on GPwSIs: The status of ‘Group3 GPwSI’, as trained and appointed prior to 2011, according to
the previous DH guidance for GPwSIs is still valid for these measures.
Governance
PCTs acting according to the DH ‘GPwSI’, guidance.
Scope of Practice
Excision (or according to clinical judgement, curettage), only of BCCs on the ‘Model 1’ list, diagnosed
by the practitioners themselves, either de novo or following referral for both diagnosis and
management, from other practitioners. Practitioners acting according to the ‘Model 1’ service model
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
25
should not knowingly excise supposed neoplastic skin lesions of any higher risk than BCCs on the
‘Model 1’ list.
Requirements of Practitioners
Competencies
Either all relevant competencies for the Group 3 GPwSIs (as given in the DH 2011 guidance as
above),
or all relevant competencies for the ‘GPwSIs in skin lesions’, in the same DH guidance.
Note: Unlike the GPwSIs in skin lesions, the Group 3 GPwSIs are deemed competent for the
management of additional, non-malignant skin conditions, outside the scope of the cancer peer
review.
Clinic Attendance
Group 3 GPwSI community skin cancer practitioners and GPwSIs in skin lesions should attend a
monthly clinic with a consultant dermatologist.
Note: This should be in the general dermatological clinical practice of the consultant and the
consultant need not be a core member of a skin cancer MDT but usually would be.
In addition they should annually attend a clinic which has a focus on skin cancer with a consultant
dermatologist who is a core member of a skin cancer MDT.
CPD
This is outlined in the DH 2011 guidance, Sections 5.1-5.3. The aspects of CPD for Model 1
practitioners which relate to the hospital skin cancer service are as follows:
•
•
Annual attendance at the skin NSSG ‘educational’ meeting and submitting feedback results
as part of the network audit, as for the DES/LES model.
Attendance at four meetings per year of a named skin cancer MDT with which they are
associated.
Note: There should be a total of 15 hours of CPD per year. The clinic attendances do not count
towards this. The NSSG meeting would be expected to count for about 4hours, and the four MDT
meetings would also count. Any further time to make up 15 hours should be made up of other
educational activities.
Other Requirements
Practitioners should:
•
•
•
•
•
•
Send all skin samples for histological analysis.
Keep records that capture the relevant parts of the national skin cancer minimum dataset.
Follow a histology requesting and reporting protocol, including ‘fail-safe mechanisms, agreed with
1
the relevant pathology laboratory.
2
Provide feedback to the commissioners or monitoring body delegated by the commissioners.
The practitioners should refer skin lesions outside the model 1 list (and those classified as ‘high
risk BCCs’ on histological grounds, following removal) according to the referral guidelines
specified in the skin cancer measures. Lesions with incomplete margins, otherwise within the
model 1 remit, may be removed either by the practitioner or a member of the skin MDT, as agreed
between them following discussion. These considerations regarding histologically incomplete
excision do not apply to lesions treated by curettage.
Be registered on a PCT-held list of accredited community skin cancer practitioners.
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
26
Numbered notes on the requirements of practitioners:
1) The protocol should include the following specifications:
o If a person has more than one lesion, samples should be sent in separate specimen pots
with separate referral forms.
o All samples should be accompanied by a checklist naming and enumerating the samples
which have been sent.
o By means of the list, any sample identified as not having been received by the laboratory
should be immediately notified to the operating practitioner.
o All results should be cross-checked against the list by the practitioners to ensure that they
have been seen and actioned.
o Reports should classify and report the following as ‘high risk BCCs’ on histological grounds;
 Those with incomplete excision margins.
 Morpheic, infiltrative, micronodular or basosquamous.
 Perineural invasion below the dermis.
2) The feedback should include:
o Numbers of cases excised and proportion completely excised.
o Pre-excision clinical diagnosis versus post excision histological diagnosis.
Note: The feedback information provides the information necessary for these community practitioners
to be incorporated into the network skin cancer audit.
SKIN SPECIFIC MEASURES
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27
3. Service Model 2
Practitioners
Registered health care professionals, either medically qualified practitioners, registered nurses, or
surgical care practitioners, all of whom are subject to the constraints given in the rest of this model.
Governance
Acute trust, associated with a named skin cancer MDT.
Scope of Practice
Excision or curettage (as directed by the referrers) of any skin cancers (other than procedures listed
as ‘hospital only’ - measure 11-2J-212) but with the provision that they have been previously
diagnosed by and have a treatment plan agreed by legitimate referrers.
Note: In order for the referrers to comply with the skin cancer measures, they would in most cases be
a skin MDT. For referrers from the independent sector to comply, they would need to have voluntarily
subjected themselves to peer review or agree to a contract which should stipulate adherence to the
cancer measures. In either case, this would mean the case would need to have passed through the
MDT process. This is what is meant by ‘legitimate referrers’. Another group of legitimate referrals
would be cases confidently, clinically diagnosed by practitioners under DES/LES or Model 1 as being
in their permitted area of practice, and referred for excision, or curettage and cautery.
Requirements of Practitioners
Competencies
The competencies agreed by a network assessor as being appropriate to their agreed area of
practice, the latter agreed with the lead clinician of the MDT under whose governance they are
working. Competence is assessed by a network trainer/assessor. (See measure 11-1C-113j)
Note: GP Practitioners who are trained and competent in the Group 3 GPwSI and skin lesion GPwSI
systems (2011 DH guidance) should be eligible, (other factors being suitable), without further
assessment, for association with an MDT as Model 2 practitioners for the scope of surgical practice
agreed as appropriate to their range of competencies.
CPD and Outcome Monitoring
This will be determined by the arrangements applying to the MDT and trust under whose governance
the practitioners are acting. It will be determined by national and professional body requirements and
be ensured by such existing systems as the trust’s appraisal process and the relevant parts of the
cancer peer review of the hospital services and cancer network.
Other Requirements
The issues outlined under this heading for Model1 practitioners and those acting under the DES/LES
system, will again be determined for Model 2 practitioners by the trust governance arrangements.
However, it would be expected that these would be no less rigorous than for the other community
practitioners, namely that they:
o
o
o
Send all skin samples for histological analysis.
Keep records that capture the relevant parts of the national skin cancer minimum
dataset.
Follow a histology requesting and reporting protocol, including ‘fail-safe
mechanisms, agreed with the relevant pathology laboratory.
Note: The protocol should include the following specifications:
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
28
•
•
•
•
•
If a person has more than one lesion, samples should be sent in separate specimen pots with
separate referral forms.
All samples should be accompanied by a checklist naming and enumerating the samples
which have been sent.
By means of the list, any sample identified as not having been received by the laboratory
should be immediately notified to the operating practitioner.
All results should be cross-checked against the list by the practitioners to ensure that they
have been seen and actioned.
Reports should classify and report the following as ‘high risk BCCs’ on histological grounds;
o Those with incomplete excision margins.
o Morpheic, infiltrative, micronodular or basosquamous.
o Perineural invasion below the dermis.
4. Service Model 3
Practitioners
Hospital medical specialists, consultant core members of skin cancer MDTs practising in the
community.
Note: This model would cover not only the above, but specialist trainees and NCCGs acting under the
supervision of and in the name of consultant specialists. Although there is no specific mention of this
aspect in the MDT cancer measures, it is accepted as a given aspect of an MDT’s hospital practice
and should be no different for community practice.
If MDT core nurse members wish to treat skin cancer in the community, currently they should be
trained as and practice as Model 2 practitioners.
Governance Framework
The acute trust via the MDT arrangements.
Scope of Practice
Whatever part of the MDT’s practice is deemed suitable for being carried out in the community,
subject to the following:
The boundaries of an MDT’s clinical practice outside the hospital setting are not explicitly specified in
the measures, but they would be constrained by:
•
•
•
The need for formal case discussion by the MDT, for cases at level 4 and above
The requirements for certain procedures to all be performed in the same hospital for the whole
of an MDTs practice
Apart from the above, the decision as to which other procedures should only be carried out in
hospital and not in the community is currently a matter for clinical judgment. Any given network
may choose to set its own protocols for this. This is not currently subject to the peer review
measures.
Requirements of Practitioners
As for hospital specialist training and MDT core membership requirements.
The Lists of Low Risk BCCs, on Clinical Criteria
1.
The list of clinically defined BCCs suitable for excision (or according to clinical
judgement, curettage) by practitioners under the DES/LES service model:
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
29
Patient
Adult, 25 and over, with normal immunity and without any genetic predisposition to BCCs.
1
Lesion
2
3
Newly presenting , nodular, definitely, clearly delineated BCC , up to 1 cm.
Site
Below the clavicle but only in cosmetically and surgically straightforward areas.
2.
4
The list of clinically defined BCCs suitable for excision (or according to clinical
judgement, curettage) by practitioners under service model 1:
The DES/LES list as above with the addition of the following, only:
An increase in size up to 2cm but only when below the clavicle.
Lesions above the clavicle up to 1 cm but only in the permitted area - the chin, cheeks, forehead,
5
temples, neck and sides of face.
General note on the lists of BCCs
These lists convey the same information as set out in the similar lists in the NICE IOG Update, of
May, 2010. In the latter, however it is expressed mainly negatively as types of lesions which are to
be excluded from a given model of service delivery. It is expressed here mainly in the form of
corresponding positive information, to comply with the general safety advice to avoid negative
recommendations.
Notes to the reference numbers on the lists of BCCs
1. Refer on patients with immunosupression (including transplant patients) or Gorlin’s syndrome.
2. Refer on patients with BCCs recurrent after previous excision and BCCs persistent (i.e.
having histologically positive resection margins) after excision.
3. Refer on BCCs of other morphological appearances, but see note on superficial BCCs, below.
4. Refer on patients with BCCs which are sited such that excision poses a potential risk to
important underlying structures, areas where difficult excision may lead to a poor cosmetic
result and areas where primary closure may be difficult.
5. Refer on patients with BCCs on the lips, nose, nasofacial sulci, nasofacial folds, periorbital
areas and ears.
Note on Superficial BCCs
Adult patients with normal immunity and without genetic predisposition to BCCs, who have superficial
BCCs, presenting to community practitioners, should be offered the choice of the full range of relevant
non-surgical treatments as well as surgical. If the patient chooses surgical treatment, the BCC may fit
into one or other of the above lists depending on its site and size characteristics, applied as above. If
the patient chooses non-surgical treatment, this may involve referral to a core member of an MDT.
For MDT interaction to operate efficiently and for patient care to be delivered seamlessly, the
following ground rules are necessary.
•
Because of the very high incidence, excellent prognosis and straightforward treatment of many
Skin Cancers, it is not necessary for all cases to be subject to a multidisciplinary treatment
planning discussion, although they may still need to be treated only by an MDT core member (see
the distinction between Care Levels 3 and 4). An MDT member may, however, bring any case for
discussion, if they consider it necessary.
SKIN SPECIFIC MEASURES
GATEWAY No. 10790 - APRIL 2011
30
•
•
•
•
•
•
Either category of practitioner and either type of MDT (LSMDT or SSMDT) may deliver levels of
care below their highest level if required, e.g. LSMDTs may deal with AK’s or precancerous
lesions.
A MDT may choose to refer to a more specialised team in certain cases, than is required by the
IOG.
Any practitioner or MDT which identifies a case as obviously needing a certain level of care, may
refer it straight to the appropriate group, e.g. a GP could refer an obvious case of melanoma,
metastatic at presentation, to the contact point of an SSMDT (or M MDT if relevant), potentially
by-passing the LSMDT if this saves time, and they know the correct referral contact point. Or, a
core member of an LSMDT, on being referred in such a case, could refer the case straight to the
SSMDT without a prior multi-disciplinary review by the LSMDT, the case being reviewed locally in
retrospect after being passed on.
It should be understood and expected that any case referred by an LSMDT to an SSMDT for
discussion, may be taken on for treatment by the SSMDT without further permission from the
referrers. Similar considerations apply to M MDTs.
The detailed clinical indications for a given case to need input from specialist surgeons or
oncologists may not be covered by any national consensus and may be subject to the prevailing
local expertise and opinion. These are areas for agreement in the Network clinical guidelines.
Provided a given case is dealt with by the MDTs, according to the levels given above, and other
relevant measures complied with, surgical excision of skin lesions may be performed by nursing
or medical practitioners in the community, trained in skin surgical competencies as specified in
the measures.
In addition to the system of authorised practitioners and MDTs outlined above, the Networks are
required to establish clinics for the management of Skin Cancer in immunocompromised patients, a
large proportion of whom will be patients with transplanted organs.
SKIN SPECIFIC MEASURES
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31
Building the Skin Cancer Network
i. Agree with PCTs the service specification of the community skin cancer service, including
accreditation arrangements, training programme and clinical governance system.
ii. Agree with PCTs the location of existing and potential clinicians, practising in the community,
according to the community skin cancer service specification.
iii. Agree the identity and location of LSMDTs.
iv. Agree the identity and location of SSMDTs.
v. Agree whether to establish MMDT(s) and, if so, their identity and location.
vi. Agree with the PCTs the arrangements for referral to and between community clinicians and
LSMDTs (including SSMDTs acting in their capacity as local teams for their own, secondary
catchment populations).
vii. Agree the location of the clinics for immunocompromised patients
viii. Agree the referral arrangements between the LSMDTs and SSMDTs (and MMDTS if relevant).
ix. Verify the catchment populations for specialist referral to SSMDTs from the populations of the
referring PCTs and LSMDTs (and, if relevant, the M MDT catchment population from the referring
LSMDT and SSMDT).
x. Agree with specialist commissioners the location of the supranetwork MDT for T-cell cutaneous
lymphoma cases requiring TSEBT.
xi. Agree with specialist commissioners, the facility for referral for photopheresis.
Reviewing the Skin Cancer Network
Regarding the different aspects of the skin cancer network; the location of the relevant measures in
the Manual for Cancer Services and who is responsible for each aspect for the purposes of peer
review, is organised as follows:
•
•
•
•
•
•
•
establishing the network site specific group (NSSG) for skin cancer; deciding the location and
distribution of MDTs, clinics for immunocompromised patients and supranetwork MDTs and
facilities are the responsibility for review purposes of the network board and are reviewed
under topic 1A in the manual;
the responsibility for review purposes for providing a clinic for immunocompromised patients
with skin cancer, lies with the relevant locality of the cancer network, with the chair of the
locality group and is reviewed under topic 1D of the manual;
the structure and functions of the NSSG for skin cancer are the responsibility for review
purposes of the chair of the NSSG and this is reviewed under topic 1C in the manual;
the structure and functions of the LSMDT are the responsibility for review purposes of the
lead clinician of the MDT and this is reviewed under topic 11-2J-1 in the manual;
the structure and functions of the SSMDT are the responsibility for review purposes of the
lead clinician of the MDT and this is reviewed under topic 11-2J-2 in the manual;
the structure and function of the MMDT are the responsibility for review purposes of the lead
clinician of the MDT and this is reviewed under topic 11-2J-3 in the manual;
the structure and functions of the supranetwork team dealing with TSEBT for selected T-cell
cutaneous lymphoma cases are the responsibility for review purposes of the lead clinician for
the MDT and this is reviewed under topic 11-2J-4 in the manual.
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TOPIC 11-1A-2j - SKIN SPECIFIC NETWORK BOARD MEASURES
TRUSTS, HOSPITALS AND SERVICES
Calman-Hine assumed that the whole of a cancer network was divided into either cancer centres or cancer
units. This works geographically in some networks where all tertiary services were grouped conveniently in
one city, serving surrounding DGHs which provided only secondary services. For many networks, things are
more complicated, so for this round of peer review, a simpler way of dividing a cancer network into
manageable parts, has been devised. Previously designated centres and units can still fit into this (see
below). The whole of each cancer network is considered to be divided into parts which the network itself
defines pragmatically on the grounds of concentrations of population and the arrangement of hospital services
and the best way that the network board judges them to be grouped for its own purpose of managing the
cancer network.
For the purpose of the peer review, these parts have to have a label. They will be known in the manual as
'localities'. The hospitals MDTs and services which make up any given locality, are entirely at the discretion of
the network.
All of the cancer network should be included in one or other locality. Each locality should have a group which
oversees it for the network - the locality group, having the representation and terms of reference set out in the
measures. The reason for the existence of localities is to ensure that the network's policies, procedures and
action plans are implemented across real services 'on the ground' and a real dialogue takes place regarding
developments and commissioning.
It can be seen from the above that:
• a previously designated 'cancer centre' or 'cancer unit', will be reviewed under this arrangement of
'localities';
• in many cases a locality will be synonymous with a trust and the palliative care services and PCTs
associated with its local catchment area.
NOMENCLATURE
Within the network measures a number of groups have been defined. These groups each need a name for the
purposes of the measures, and for data collection for the peer review. The names are purely labels for the
measures. Provided a group is formed and put forward for assessment against the appropriate set of
measures, the name used locally is a local matter. The result of its review will be recorded and collated for the
network database under its measures' name, to avoid confusion.
The overall management group has changed its name in the measures from round one "network management
group" to "network board", to reflect the terminology in the document "Shifting the Balance of Power - The
Next Steps". It is meant to be the same body, although its required membership and scope have expanded.
As explained above, cancer centre groups and cancer unit groups, as referred to in the round one measures,
have been replaced by the more generic and flexible concept of the 'locality group', but the continued local
use of the former names is entirely at local discretion and such groups (possibly needing modification of
membership, etc) should be put forward for review against the locality group measures.
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Responsibility for review purposes for measures 11-1A-201j to 11-1A-216j lies with the Chair of the Network
Board.
ESTABLISHMENT OF NETWORK SITE SPECIFIC GROUPS (NSSGs)
Agreed Named Members and Terms of Reference of NSSG
11-1A-201j
There should be a single NSSG, having membership fulfilling the following:
the MDT lead clinician from each MDT in the network;
at least one nurse core member of a MDT in the network;
there should be a named chair drawn from the above membership;
two user representatives;
one of the NHS employed members of the NSSG should be nominated as having
specific responsibility for users' issues and information for patients and carers;
• a GPwSI in skin cancer practicing in the community;
• a member of the NSSG responsible for ensuring that recruitment into clinical trials
and other well designed studies is integrated into the function of the NSSG;
• named secretarial/administrative support.
•
•
•
•
•
There should be terms of reference agreed for the NSSG which include:
The NSSG being recognised as:
• the board's primary source of clinical opinion on issues relating to skin cancer for the
network;
• the group with corporate responsibility, delegated by the board, for co-ordination and
consistency across the network for skin cancer policy, practice guidelines, audit,
research and service improvement;
• consulting with head relevant 'cross cutting' network groups on issues involving
chemotherapy, cancer imaging, histopathology and laboratory investigation and
specialist palliative care, with the head of service on issues involving radiotherapy,
and with PCTs on issues involving the community skin cancer service.
Notes:
• There may be additional agreed members and attendance at an individual meeting
need not be limited to the agreed members. If the local user group do not wish, or
are unable, to nominate a user representative, but there is an agreed mechanism for
obtaining user advice, then the measure will be deemed to have been complied with.
• There may be additional points in the agreed terms of reference. Recommendations
may be found in appendix 2.
Compliance:
The named members and NSSG chair agreed by the Chair of the Network Board.
The terms of reference agreed by the Chair of the Network Board and the Chair of the
NSSG.
IOG IMPLEMENTATION SUMMARY
Agreed Network IOG Implementation Summary
11-1A-202j
The Network Board should agree an implementation summary, with the SCG, meeting
the following criteria:
i)
it should explicitly mention the separate steps needed to build the skin cancer
network as specified in the introduction to the skin cancer measures;
ii) it should identify when the milestones for development of skin cancer networks are
planned to be reached;
iii) it should be signed off by:
• the Chair of the Network Board;
• a CE representative of the trusts in the network;
• a CE representative of the PCTs in the network;
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
• a representative of the SCG relevant to the network.
Notes:
• The agreed summary does not exempt the network from being assessed against the
rest of the skin cancer measures at a peer review visit.
• Agreement in principle with PCTs and the SCG is needed but this is an IOG
implementation summary and agreement does not imply binding contractual
arrangements between parties.
Compliance:
The summary agreed by those specified above.
PROVISION OF SKIN CANCER SERVICES IN THE COMMUNITY
This measure has been withdrawn
11-1A-203j
NETWORK CONFIGURATION OF TEAMS
Network Configuration of MDTs
11-1A-204j
The Network Board should agree in consultation with the NSSG and cancer lead
clinicians of each trust in the network, the list of local and specialist skin MDTs in the
network and their host hospital, (and melanoma MDTs if relevant) each team complying
with the team criteria as follows:
The local skin MDT (LSMDT) should be:
• the only skin MDT (local or specialist) in the host hospital;
• named as a component of one of the localities of the network.
The specialist skin MDT (SSMDT) should be:
•
•
•
•
•
the only skin MDT (local or specialist) in its host hospital;
named as a component of one of the localities of the network;
the only SSMDT in its host trust;
functioning as the LSMDT for its own local (secondary) referral population;
having a catchment population for specialist (level 5) referral of at least 750,000.
The melanoma MDT (MMDT) should be:
• the only MMDT in the network and taking all referrals of malignant melanoma for
level 5 care from their catchment population;
• taking all referrals of malignant melanoma for level 4 care from their local
(secondary) catchment population;
• agreed as part of a named locality in the cancer network;
• having a catchment population for specialist (level 5) care for malignant melanoma,
of at least 750,000.
This list is known as the network configuration for LSMDTs, SSMDTs and MMDTs.
Note:
The cancer network may choose not to have a MMDT.
The Network Board should agree, in consultation with the NSSG and the lead clinician of
each SSMDT in the network, the catchment populations for referral for specialist care to
named SSMDTs.This should be a minimum of 750,000. The population should be
estimated in each case from the catchment populations of their respective referring
LSMDTs.
Notes:
• All SSMDTs should be offered for review against this measure.
• Where there is a MMDT the catchment population should also be at least 750,000.
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Compliance:
The network configuration agreed by the Chairs of the Network Board and the Chair of
NSSG and the trust lead cancer clinicians.
Evidence for team criteria is self evident from:
• the number of teams and their location;
• the facilities and services of the host trusts;
• their referral agreements showing that specialist MDTs also serve their local
populations.
A list of each named SSMDT (and MMDT where relevant) in the network with the relevant
catchment population signed by the Chair of the Network Board, Chair of the NSSG and
the relevant MDT lead clinicians.
Notes:
• When SSMDTs receive referrals from other networks, the catchment population of
the referring LSMDTs from the other networks should be counted towards the total
catchment of the receiving SSMDT.
• For the network to comply with this measure all SSMDTs and MMDTs in the network
should have a catchment population of 750,000 or more.
NETWORK CONFIGURATION FOR THE COMMUNITY SKIN CANCER SERVICES
This measure has been withdrawn
11-1A-205j
Network Agreed Referral Patterns Between Named PCTs and LSMDTs
11-1A-206j
The Network Board should agree with PCT leads and the NSSG, the named PCTs or
named individual practices which will refer patients to which named MDT, one practice
referring to one team.
Notes:
• This includes SSMDTs acting in their capacity as local teams for their own local
(secondary) catchment population.
• The principle of a given primary care practice or PCT stating that patients will be
referred to a given MDT is not intended to restrict patients or GP choice. A rational
network of local and specialist MDTs can only be developed if
i) there is an agreement on which MDT the patients will normally be referred to and
ii) the resulting referral catchment populations are counted once for planning
purposes.
It is accepted that individual patients will, on occasion, be referred to different teams,
depending on specific circumstances. For instance, there is special provision in the
skin cancer IOG for doctors working in the community to refer patients meeting the
necessary criteria, directly to the SSMDT for specialist review.
Compliance:
The list of named teams and their host hospitals and their referring PCTs or individual
practices.
The list should be agreed by the chairs of the Network Board and the NSSG and a
representative of the PCTs.
Introduction to measures 11-1A-207j to 11-1A-209j
In view of:
• the various possible network configurations for the MDTs and the need to have agreed the particular
configuration for the whole network, the responsibility for review purposes for the referral guidelines
between LSMDTs, SSMDTs, MMDTs and supranetwork teams, lies with the lead clinician of the MDT,
the Chair of the NSSG and Chair of the Network Board.
For compliance, the Network Board in consultation with the NSSG should produce agreed guidelines and
the individual MDT, for their compliance, should agree to abide by them. The measures count towards the
review of the network board and the individual team. Network guidelines should be reviewed at least every
three years or when new guidance is available.
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Network Agreed Referral Guidelines Between Teams
11-1A-207j
The Network Board should, in consultation with the NSSG, agree referral guidelines
between LSMDTs, SSMDTs and the supranetwork teams which include the following:
• that LSMDTs should refer cases of the types of skin cancer needing care level 5 as
in the introduction to the skin cancer measures, to a named SSMDT for discussion
and management, stating which named LSMDTs will refer to which named
SSMDTs;
• if there is more than one SSMDT in the network, the single named SSMDT to which
each of the following types of case should be referred:
• cutaneous lymphoma;
• kaposi's sarcoma;
• cutaneous sarcoma above superficial fascia;
• other rare skin cancers see appendix 1 of the IOG on page 128/129.
Notes:
• Where there is a MMDT the guidelines should state which LSMDTs and SSMDTs
should refer level 5 cases to the MMDT.
• LSMDTs may make referrals to SSMDTs in another network and SSMDTs may
receive referrals from a LSMDT in another network. These inter-network
arrangements should be agreed and stated, naming teams and their host hospitals.
The responsibility for these inter-network arrangements lies for review purposes,
with the referring network board and the referring MDT.
• Regarding referral of specified skin cancer types to a single SSMDT, although each
type in the list should be referred to a single SSMDT, they do not all need to be
referred to the same SSMDT. If there is only one SSMDT in the network, this issue
does not apply.
Compliance:
The guidelines, naming MDTs and their host hospitals agreed by the Chair of the Network
Board and the Chair of the NSSG.
Agreed Network Referral Guidelines to Named Supra-network T-cell Lymphoma MDT for TSEBT
11-1A-208j
The Network Board should, in consultation with the skin cancer NSSG, agree with the
specialist commissioners a guideline which specifies:
i)
that cases of nodular mycosis fungoides (stage 2B or over) should be referred for
discussion and consideration of TSEB;
ii) the named, supranetwork MDT which the network will use for this function.
Notes:
• This team will in most cases, be in another network. If the network under review is
hosting such a team, this should be declared and agreed with the specialist
commissioners as the demonstration of compliance.
• This team should be put forward by its host network, for review against topic
11-2J-4.
Compliance:
The guideline including the named supranetwork MDT agreed by the Chair of the Network
Board, the Chair of the NSSG and a representative of the specialist commissioners.
REFERRAL FOR PHOTOPHERESIS
Agreed Network Guidelines for Referral for Photopheresis
11-1A-209j
The Network Board should, in consultation with the skin cancer NSSG, agree with the
specialist commissioners, a guideline which specifies:
that cases of erythrodermic cutaneous T-cell lymphoma, stages 3 and 4, having both
skin involvement and circulating T-cell clonal cells, should be discussed with the clinician
in charge of a named photopheresis facility for potential referral and treatment by
photopheresis; the named facility which the network will use.
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Compliance:
The guideline, naming the photopheresis facility agreed by the Chair of the Network
Board, the Chair of the NSSG and a representative of the specialist commissioners.
Note:
The facility will be in another network in most cases.
Agreed Network Distribution of Clinics for Immunocompromised Patients with Skin Cancer
11-1A-210j
The Network Board should agree in consultation with the NSSG and cancer lead
clinicians of each trust in the network, which localities will staff and run a clinic for
immunocompromised patients with skin cancer.
The network should designate at least one such clinic, and (in addition, if necessary) any
locality which contains a trust which hosts a centre for renal and/or liver and/or cardiac
transplants should be required by the network to run such a clinic.
Note:
These localities should be put forward for review against the relevant measure in topic
11-1D.
Compliance:
The named locality or localities agreed by the Chair of the Network Board, the Chair of the
NSSG and the trust cancer lead clinicians.
The reviewers should enquire as to the distribution of organ transplant centres in the
cancer network.
Arrangements for Head and Neck Skin Cancer
11-1A-211j
The Network Board should agree network guidelines with the head and neck, and skin
cancer NSSGs which specify the following:
i)
for nasal mucosal melanoma which MDTs, out of the head and neck cancer MDTs
or skin cancer should deal with these cases in which clinical situations and parts of
the patient pathway;
ii) for ocular mucosal melanoma MDTs or others, should deal with these cases and in
which clinical situations and parts of the patient pathway;
iii) for periocular skin cancer MDTs should deal with these cases and in which clinical
situations and parts of the patient pathway
iv) for other head and neck or skin cancer MDTs should deal with these cases and in
which clinical situations and parts of the patient pathway.
Compliance:
For each of the categories i. to iv. above, the named MDTs for specified clinical situations
and parts of the patient pathway agreed by the Chairs of the Network Board, head and
neck and skin cancer NSSGs.
Arrangements for Anal and Perianal Skin Cancer
11-1A-212j
The Network Board should agree network guidelines with the colorectal and skin cancer
NSSGs, which specify the following:
• for anal and perianal cancer, which MDTs out of the anal cancer MDTs and skin
cancer MDTs, should deal with these cases and in which clinical situation and parts
of the patient pathway.
Compliance:
The named MDTs for specified clinical situations and parts of the patient pathway agreed
by the Chairs of the Network Board, colorectal and skin cancer NSSGs.
Arrangements for Skin Cancer of External Female Genitalia
11-1A-213j
The Network Board should agree network guidelines with gynaecology and skin cancer
NSSGs, which specify the following:
• for cancer of the external female genitalia, including mucosal melanoma, which
MDTs out of the gynaecology MDTs and skin MDTs, should deal with these cases
and in which clinical situations and parts of the patient pathway.
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Compliance:
The named MDTs for specified clinical situations and parts of the patient pathway agreed
by the Chairs of Network Board, gynaecology and skin cancer NSSGs.
Arrangements for Skin Cancer of External Male Genitalia
11-1A-214j
The Network Board should agree network guidelines with urology and skin cancer
NSSGs, which specify the following:
• for cancer of the external male genitalia, including mucosal melanoma, which MDTs
out of the urology MDTs and skin MDTs, should deal with these cases and in which
clinical situations and parts of the patient pathway.
Compliance:
The named MDTs for specified clinical situations and parts of the patient pathway agreed
by the Chairs of Network Board, urology and skin cancer NSSGs.
Arrangements with Haemato-oncology Teams for Lymphoma Involving Skin
11-1A-215j
Compliance:
The Network Board should agree network guidelines with haemato-oncology and skin
cancer NSSGs, which specify that systemic/nodal lymphomas presenting in the skin,
should be referred to a haemato-oncology MDT and primary cutaneous lymphoma
should be referred to an SSMDT agreed by the network as dealing with cutaneous
lymphoma.
The named MDTs and the clinical indications for referral agreed by the Chairs of Network
Board, haemato-oncology and skin cancer NSSGs.
Arrangements with Sarcoma MDTs for Sarcoma Involving Skin
11-1A-216j
The Network Board should agree network guidelines with the sarcoma which deals with
the sarcoma relevant to the network under review, and the skin cancer , which specify
the following:
• for sarcomas involving the skin, which MDTs out of the sarcoma MDT and the skin
MDTs should deal with these cases, and in which clinical situations and parts of the
patient pathway.
Note:
The guidelines should be compatible with the IOG recommendations that sarcomas
which are large or involve or penetrate the superficial fascia and those of histological
types potentially requiring chemotherapy should be referred to the sarcoma MDT.
Compliance:
SKIN SPECIFIC MEASURES
The named MDTs for specified clinical situations and parts of the patient pathway agreed
by Chairs of Network Board, sarcoma and skin cancer NSSGs.
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TOPIC 11-1C-1j - FUNCTIONS OF NETWORK SITE SPECIFIC GROUPS (NSSGs)
Introduction
The measures in this section should be applied separately to each NSSG in the network.
If a network has MDTs for any given cancer site, but has no NSSG, the results for this section, regarding that
cancer site, should be classed as 'non-compliant'.
The responsibility for review purposes for measures dealing with the function of NSSGs lies with the chair of
the group.
MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
GENERAL ACTIVITIES
NSSG Meeting
11-1C-101j
The NSSG should meet regularly and record attendance.
Note:
The attendance of MDT representatives is reviewed in the measure for each MDT.
Compliance:
A list of meetings and attendance records in the last 12 months.
Annual Review, Work Programme and Annual Report
11-1C-102j
The Chair of the NSSG should have an annual review with the network lead clinician
and/or appropriate member of the network board.
The NSSG should have agreed an annual work programme with the board.
The NSSG should have produced an annual report for the board.
Compliance:
Documentation sufficient to show that a review meeting took place with the network lead
clinician and/or appropriate member of the Network Board.
The annual work programme agreed by the Chair of the Network Board.
The annual report, agreed by the chair of the NSSG and the Chair of the Network Board.
Note:
This meeting should be face to face. An email is not an acceptable mechanism for the
review.
Agreed Minimum Dataset
11-1C-103j
The NSSG should agree a network-wide minimum dataset (MDS). The MDS should
include the data items required for:
• the cancer waiting times monitoring, including Going Further on Cancer Waits, in
accordance with DSCN 20/2008, to the specified timetable as specified in the
National Contract for Acute Services;
• the Cancer Registration Dataset as specified in the National Contract for Acute
Services.
The MDS must include all items required for the national contract, any additional items
should use definitions and codes taken from the National Cancer Dataset and the NHS
Data Dictionary.
Note:
The NSSG may agree additional data items.
The NSSG should agree a network-wide policy specifying:
• which team should collect which portion of the MDS;
• when each data item should be captured on the patient pathway;
• how the data will be stored and managed within all appropriate local data systems.
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Compliance:
The MDS and policy for collection agreed by the Chair of the NSSG and the Chair of the
Network Board.
Note:
The NSSG for their compliance with this measure should, in consultation with the MDTs,
agree the MDS, and the individual MDTs, for compliance with their relevant measure,
should agree to collect it.
NETWORK AUDIT
Introductory Notes
For review purposes a network audit project is an audit project related to the cancer site or sites of the
NSSG and the activities of its MDTs. The same project should be carried out by all MDTs for that cancer
site in the network, each team's results being separately identified. The individual MDTs, for compliance
with their relevant MDT measure, should agree to participate in the audit. See appendix 1 for audit.
Network Audit
11-1C-104j
The NSSG should agree at least one network audit project with the Network Board.
Notes:
• See appendix 1 for audit;
• Additional projects may be agreed.
The NSSG should annually review the progress of the network audit project or discuss
the results of the completed network audit project.
Compliance:
The audit agreed by the Chair of the NSSG and the Chair of the Network Board.
Written confirmation of an annual review sufficient to show compliance with the measure.
Discussion of Clinical Trials
11-1C-105j
The NSSG should discuss at least annually, the report on clinical trials from each of its
MDTs (see relevant MDT measures).
The following should be present at the discussion:
•
•
•
•
the Chair of the NSSG or a nominated representative;
the NSSG research lead;
the lead clinician of the MDT or nominated representative from that MDT;
the clinical lead of the research network or a nominated representative from the
research network.
A programme for improvement for clinical trial entry for the MDT should be agreed at the
discussion.
Compliance:
Confirmation of discussions, sufficient to show compliance with the measure, including
those present.
The programmes for improvement, agreed by the lead clinicians of the MDTs and the
clinical lead for the cancer research network.
Notes:
The discussion with various individual MDTs may take place at different meetings of the
NSSG. All of the MDTs of the NSSG need to have attended such a meeting for the
measure to be compliant.
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PROPOSALS FOR SERVICE DEVELOPMENTS
Network Agreed Three Year Service Development Plan
11-1C-106j
Compliance:
The NSSG should agree proposed service developments for its cancer site, for the three
contracting years, as advice to the board, for the network proposed service delivery plan.
The plan agreed by the Chair of the NSSG.
CLINICAL GUIDELINES
Introduction
The skin cancer IOG covers several types of skin cancer and the guidelines for referral of cases between
teams may involve network reconfiguration of the service. Therefore, for the purpose of peer review, the
guidelines for referral between teams are the responsibility of the network board to agree, in consultation
with the NSSG. Therefore, they appear in topic 11-1A, not here in topic 11-1C.
Also, for simplicity's sake, the measures for clinical, imaging and pathology guidelines are formatted so that,
each of them is intended to cover all the different types of skin cancer in one measure.
The measure below should be applied to the NSSGs for all published tumour group measures.
For their compliance with the measure below, the NSSG should, in consultation with the MDTs, produce the
network-wide clinical guidelines. Each individual MDT, for their compliance with the relevant measure on
clinical guidelines in the MDT section, should agree to them.
Network Agreed Clinical Guidelines
11-1C-107j
The NSSG should agree network-wide clinical guidelines (how a given patient should be
clinically managed, usually at the level of which modality of treatment is indicated, rather
than detailed regimens or surgical techniques).
Also, regarding the skin cancer 'levels of care' as specified in the introduction to the skin
cancer measures; besides the specific case mix and procedures which make up each
level, the NSSG should agree any other parameters for the network, which should
determine whether a case should be referred for the opinion of:
i) a surgical and
ii) an oncological core member of the SSMDT;
iii) and for associated MDT review.
Note:
More details of regimens and techniques may be agreed if desired.
Compliance:
The clinical guidelines agreed by the Chair of the NSSG and the Chair of the Network
Board.
IMAGING GUIDELINES
For their compliance with this measure, the NSSG should, in consultation with the MDTs and the network
imaging group, produce the network-wide imaging guidelines. Each individual MDT, for their compliance
with the relevant measure on imaging guidelines in the MDT section, should agree to them.
Network Agreed Imaging Guidelines for Diagnosis and Assessment
11-1C-108j
The NSSG should agree network-wide imaging guidelines for the diagnosis and
assessment of skin cancer. The guidelines should address:
• imaging modalities;
• their specific indications.
Compliance:
SKIN SPECIFIC MEASURES
The imaging guidelines agreed by the Chair of the NSSG and the Chair of the Network
Board.
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PATHOLOGY GUIDELINES
For their compliance with this measure, the NSSG should, in consultation with the MDTs and the network
pathology group, produce the network-wide pathology guidelines. Each individual MDT, for their compliance
with the relevant measure on pathology guidelines in the MDT section, should agree to them.
Network Agreed Pathology Guidelines for Diagnosis and Assessment
11-1C-109j
The NSSG should agree network-wide pathology guidelines for the diagnosis and
assessment of skin cancer.
The guidelines should address:
• laboratory and histopathology/histochemical investigations;
• their specific indications.
The guidelines should include the following:
• the pathology requesting and reporting protocol with failsafe mechanisms, applicable
to community and hospital practice. (See the 'Management of Skin Cancer in the
Community' section in the introduction to these skin cancer measures);
• that there should be a named histopathologist for the network, to whom all new
presumed cases of cutaneous lymphoma, should be referred for a second histology
opinion.
Note:
This pathologist would normally be a core histopathology member of the single SSMDT
dealing with cutaneous lymphoma, for the network.
• that cases referred to an SSMDT (or MMDT if relevant) from another MDT should be
subject to a review of their histology by a core histopathologist member of the
SSMDT.
Compliance:
The pathology guidelines agreed by the Chair of the NSSG and the Chair of the Network
Board, naming the network pathologist for cutaneous lymphoma.
PRIMARY CARE REFERRAL GUIDELINES
Network Agreed Primary Care Referral Guidelines
11-1C-110j
The NSSG in consultation with the PCTs should agree referral guidelines for GPs, which
include the following as far as they are relevant to the network's agreed configurations
for hospital based and community based services:
i)
that actinic keratoses and precancerous lesions may be dealt with by any GP (level
1 care. See the introduction to skin cancer measures);
ii) that GPs should refer suspected cases of skin cancer requiring treatment, including
BCCs, to the contact point of the relevant named MDTs in the network
configurations ( see Measure 11-1A-204j ), or for cases of low risk BCC there is the
option of referral to the contact point of a relevant GP based service;
iii) the contact points of any relevant community based services;
iv) the guidance for GPs on clinically identifying low risk BCCs incorporating the lists of
clinically low risk BCCs.
The primary care referral guidelines should be distributed to the hospital core members
of the LSMDTs and the SSMDTs in the network.
Notes:
• It is inevitable that SCCs and other tumours outside the remit of GPs will be excised
accidentally by them, when diagnosis is not clinically apparent. The guidelines are
underpinned by an assumption that GPs will not knowingly treat patients beyond
their remit.
• The distribution of the primary care referral guidelines to primary care practitioners
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themselves is considered for the purpose of peer review, to be the responsibility of
the PCT.
Compliance:
The primary care referral guidelines, agreed by the Chair of the NSSG, and a
representative of the PCTs, naming the contact points for the MDTs and community skin
cancer services, as relevant.
The reviewer should enquire as to the distribution process.
Note:
Minor shortcomings in the completeness of the distribution should not prevent compliance
with this measure.
MOHS SURGERY
NSSG Designated Hospital Practitioners for Mohs Surgery
11-1C-111j
The NSSG should name those hospital practitioners which the network authorises as the
only practitioners to carry out the procedure known as Mohs surgery, for the network.
This includes the procedure known as 'Slow Mohs surgery'.
Each named practitioner should have carried out a total of at least 50 complete Mohs
surgical procedures per year averaged over the last two complete calendar years prior to
the networks peer review visit or completed self-assessment.
Note:
The named practitioners may be in another network and cases are referred to them, but
their compliance regarding minimum case numbers still counts towards the compliance
of the referring network, under review.
Compliance:
The named practitioners, each with their individual averaged case numbers, agreed by
the Chair of the NSSG and the Chair of the Network Board.
CLINICAL GOVERNANCE OF COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-1C-112j
TRAINING FOR MODEL 2 COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-1C-113j
CHEMOTHERAPY TREATMENT ALGORITHMS
Introduction
• For the purposes of peer review, a chemotherapy regimen is defined by the therapeutic chemotherapy
drugs used, often expressed as an acronym e.g. 'FEC'. A change of one or more of these drugs
themselves would normally be necessary for it to be classed as a change of regimen. In some cases
major changes in the dose or route of administration of one or more of the drugs effectively changes
the regimen but these cases are generally known and recognised nationally. A given network is free to
choose any further changes which they classify as changing the regimen, as long as it is in accord with
the above definition and national exceptions; i.e. they are free to make the definition of a regimen
narrower, but not wider.
• For the purposes of peer review, a chemotherapy treatment protocol is defined as constituting all the
parameters specified in the bullet points in chemotherapy measure 11-3S-122. A change in any of
these parameters would change the treatment protocol but any change other than the therapeutic
drugs themselves (apart from the national and local exceptions specified above) would change only the
protocol, not the regimen as well.
• For the purposes of peer review a chemotherapy treatment algorithm may be described as a guideline
which specifies the acceptable ranges of regimen options for named steps on the patient pathway.
Treatment algorithms are cancer site-specific. They are not specific to individual patients, i.e. they are
not individual treatment plans. Thus, a treatment algorithm for breast cancer would include a statement
of the range of regimens agreed as acceptable for adjuvant chemotherapy and for first, second and
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
third line palliative chemotherapy etc. Illustrative examples of treatment algorithms in different formats
may be found in appendix 1 in the chemotherapy measures. There may be other formats which would
be acceptable to the reviewers. Thus, a change of regimen or order of regimens may no longer comply
with a previous treatment algorithm, but a change of one of the minor aspects of a treatment protocol
would still comply.
Chemotherapy Treatment Algorithms
11-1C-114j
The NSSG, in consultation with the Network Chemotherapy Group (NCG) should agree
a list of acceptable chemotherapy treatment algorithms. It should be updated bi-annually.
Notes:
• The intention is not to require a single mandatory regimen for each clinical
indication. It is to prevent individual practitioners having unorthodox, obsolete and
unpredictably varying practice, which is against the opinion of their peers within the
network.
• The NSSG should produce the algorithms for its compliance with this measure and
the chemotherapy multi-professional team should produce a compatible list of
algorithms for the NSSG's cancer site for their own service (measure 11-3S-122).
• The chemotherapy multi-professional team should agree lists with all the NSSGs
relevant to their practice, for compliance with their measure.
• The network algorithm for a particular clinical situation may have a number of
alternative regimens of which the multi-professional team need only agree those
which it intends to use in its service. The multi-professional team need only address
those clinical indications which are applicable to the scope of its practice. The key
requirement is that all the algorithms on the multi-professional team list are
compatible with the NSSG agreed list.
• This exercise should include oral chemotherapy.
• This measure is assessed as part of the responsibility of each NSSG, but from the
NCG's point of view regarding the management of this process, the algorithms don't
all need to be updated at the same time. It would seem sensible, however, to update
all those for a given cancer site, at the same time.
Compliance:
The algorithms in place prior to the self assessment/peer review visit agreed by the Chair
of the NSSG, and the Chair of the NCG.
For NSSGs meeting for three or more years since the publication of the measures, the
algorithms are needed from the first year, then the agreed updates every two years up to
the self assessment/peer review visit.
The TYACN Pathway for Initial Management
11-1C-115j
The NSSG should agree, with the chair of the relevant TYACNCG, the TYACN patient
pathway for initial management, including any features specific to the NSSG's cancer
site and their host adult cancer network and incorporating their relevant MDT contact
numbers.
The NSSG should distribute the pathway to the lead clinicians of the MDTs of their
cancer site in their host cancer network.
Compliance:
The pathway, agreed by the Chair of the NSSG and the chair of the relevant TYACNCG.
The reviewers should check that it fulfils the features above.
The reviewers should enquire as to the distribution process.
Note:
The TYACNCG should, for compliance with their relevant measure, produce the pathway
and the NSSG, for compliance with this measure, should agree to abide by it, add local
contact points and distribute it.
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
The TYA Pathway for Follow Up on Completion of First Line Treatment
11-1C-116j
The NSSG should agree, with the chair of the relevant TYACNCG the TYACN patient
pathway for follow up on completion of first line treatment including any features specific
to the NSSG's cancer site and their host adult cancer network and incorporating their
relevant MDT contact numbers.
The NSSG should distribute the pathway to the lead clinicians of the MDTs of their
cancer site in their host cancer network.
Compliance:
The pathway, agreed by the Chair of the NSSG and the chair of the relevant TYACNCG.
The reviewers should check that it fulfils the features above.
The reviewers should enquire as to the distribution process.
Note:
The TYACNCG should, for compliance with their relevant measure, produce the pathway
and the NSSG, for compliance with this measure, should agree to abide by it, add local
contact points and distribute it.
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TOPIC 11-1D-1j - FUNCTIONS OF THE LOCALITY GROUP
MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
PROVISION OF CLINIC FOR IMMUNOCOMPROMISED PATIENTS WITH SKIN CANCER
Introduction
This measure should be applied to the locality groups which according to the network agreement (topic
11-1A-210j), should establish clinics for immunocompromised patients with skin cancer, in their locality. It
should be applied separately for each clinic in the locality (although there is unlikely to be more than one)
and the compliance regarding each clinic should count separately towards the review of the locality groups.
If the locality is not agreed as providing a clinic, this measure is not applicable. If the locality is agreed as
providing a clinic but has not provided one, this measure should be applied but counted as non-compliant.
The responsibility, for review purposes, for measure 11-1D-101j lies with the Chair of the Locality Group.
Provision of Clinics for Immunocompromised Patients with Skin Cancer
11-1D-101j
There should be a regular clinic in one of the hospitals of the locality which:
• should be identified on the hospital outpatient department clinic list or timetable as a
clinic for immunocompromised patients with skin cancer;
• should have bookable numbered clinic slots identified for the above patients;
• has clinic medical staff which include core dermatologist members of a named MDT
or MDTs, and it features on their job plans;
• should be part of the workplan or job description of a nurse specialist member of the
MDT(s).
Notes:
• The clinic may be part of an existing clinic provided conditions above are fulfilled.
• There may be other clinic medical and nursing staff in addition to those specified.
Compliance:
Identification of the hospital(s) outpatient department clinic(s) with booking rules.
The named MDT(s).
Confirmation that the clinic features in the consultant and nurse specialist work plan.
SKIN SPECIFIC MEASURES
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TOPIC 11-2J-1 - SKIN CANCER MULTIDISCIPLINARY TEAM (MDT)
When is a Team a Team and When is it not a Team?
The measures review a variety of aspects of the team, both structure and function, but the key question which
underlies all this is who exactly constitutes the MDT from the point of view of the peer review? Which group of
people should be put forward for review against these measures and who is it who is held compliant or not
compliant? This is best answered from the patient's point of view. If you were a patient, who would you
consider to be your MDT? Primarily it is that group of people of different health care disciplines, which meets
together at a given time (whether physically in one place or by video or tele-conferencing) to discuss a given
patient and who are each able to contribute independently to the diagnostic and treatment decisions about the
patient. They constitute that patient's MDT.
The way the MDT meeting itself is organised is left to local discretion such that different professional
disciplines may make their contributions at different times, without necessarily being present for the whole
meeting, in order to prevent wastage of staff time. The key requirement is that each discipline is able to
contribute independently to the decisions regarding each relevant patient. For some cancer types the IOG has
laid down detailed requirements over how the diagnostic process should be incorporated into the MDT system
and this has also been translated into the measures where applicable.
Two or more groups of people who may have declared an alliance to form a so-called 'combined' MDT but
who do not all meet together to collectively contribute to the decisions on a given patient as specified above,
do not constitute an MDT from the point of view of peer review. Such alliances have been attempted in order
to achieve, for instance, a minimum caseload or catchment population. This is not appropriate. Each separate
group, meeting as specified above, should be assessed separately against such criteria.
In general the measures should be applied to that defined group, but there are some functions for which
MDTs may combine in a way which is appropriate. Then, the evidence put forward to demonstrate their
compliance with the relevant measures may serve as common evidence across the MDTs but it is applied
separately and compliance is awarded separately to each team.
The main examples of this are as follows:
• a combined operational policy meeting but the policies are agreed on behalf of each MDT by its lead
clinician;
• network-wide clinical, referral, imaging and pathology guidelines, but each MDT agrees to abide by them;
• the same network-wide project for network audit, but each MDT agreeing to participate;
• a common minimum dataset, but each MDT agrees to collect its portion of it;
• a network list of approved trials but each MDT agrees to enter patients;
• an individual health professional being a member of more than one MDT, but a particular defined and
named set of people make up a given MDT.
As well as meeting to make the combined multidisciplinary decisions about patients, the members of some
types of MDTs are required by the measures to carry out another key function in company with other specified
personnel. Thus, some of the more complex surgical procedures should all be performed by the same group
of professionals - surgeon, anaesthetist and skilled theatre and aftercare staff. This is ensured by requiring
services to be organised for that MDT so that all cases of a given procedure are performed in the same
hospital. The people will largely be a different set of people from those who meet to make the diagnostic and
treatment decisions (the MDT as defined in the measures)
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48
but they will directly relate to that MDT and be specified by it, because at least one key functionary, the
surgeon, will be a core member of that MDT.
In requiring all the complex procedures to be performed in the same hospital of the MDT ties in the referral
catchment population of the MDT to that hospital. This provides a direct link between the referring catchment
population for MDT discussion and the treatment caseload of the treatment team and its hospital facilities.
When is a Patient, a Patient and When are they not a Patient?
In the case of LSMDTs (and SSMDTs acting in their role of LSMDT to their local catchment), where the
wording of a measure refers to patients; for the purpose of review, this applies only to those patients whose
case is subject to formal, individual MDT discussion, unless stated otherwise.
The requirements for the large group of patients who are dealt with by authorised clinicians in the community
or by hospital based MDT members, but without individual MDT discussion (level 3 care, see introduction to
the skin cancer measures), are met by the measures concerned with quality assurance of community practice
and the skin cancer network audit.
MDTs may wish to extend various aspects of their working practices as specified in the measures to this wider
group of patients (e.g. patient written information). This is at their discretion and is largely to be encouraged
but it will not affect their compliance with the measures.
MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
The responsibility, for review purposes, for measure 11-2J-101 lies with the lead clinician of the host trust
(see topic 11-1A).
MDT STRUCTURE
Lead Clinician and Core Team Membership
11-2J-101
There should be a single named lead clinician for the MDT who should then be a core
team member.
The lead clinician of the MDT should have agreed the responsibilities of the position with
the lead clinician of the host trust.
Note:
The role of lead clinician of the MDT should not itself imply chronological seniority,
superior experience or superior clinical ability.
The MDT should provide the names of core team members for named roles in the team.
The core team specific to the skin cancer MDT should include:
two dermatologists;
a histopathologist;
skin nurse specialist;
MDT co-ordinator/secretary;
a NHS-employed member of the core or extended team should be nominated as
having specific responsibility for users' issues and information for patients and
carers;
• a member of the core team nominated as the person responsible for ensuring that
recruitment into clinical trials and other well designed studies is integrated into the
function of the MDT.
•
•
•
•
•
Notes:
• Each clinical core member should have sessions specified in the job plan for the
care of patients with skin cancer and attendance at MDT meetings.
• Where a medical specialty is referred to, the core team member should be a
consultant. The cover for this member need not be a consultant. Where a medical
skill rather than a specialty is referred to, this may be provided by one or more of the
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
core members or by a career grade non-consultant medical staff member. The
medically qualified core member(s) depend on the cancer site of the MDT.
• The co-ordinator/secretary role needs different amounts of time depending on team
workload. See appendix 2 for an illustration of the responsibilities of this role. The
co-ordinator and secretarial role may be filled by two differently named individuals or
the same one. It need not occupy the whole of an individual's job description.
• There may be additional core members agreed for the team besides those listed
above. In particular, note that if there is no consultant surgeon as a core member,
the team should name one of the surgical core members of the relevant SSMDT, as
a member of the extended team for the LSMDT.
Compliance:
Named lead clinician for the MDT agreed by the lead clinician of the host trust.
The written responsibilities agreed by the lead clinician of the MDT and lead clinician of
the host trust.
Note:
See appendix 2 for an illustration of the responsibilities of this role.
Name of each core team member with their role, agreed by the lead clinician of the host
trust.
Notes:
The reviewers should record in their assessment each case where the post(s) needed to
provide the minimum core membership for a given listed role in the measure is unfilled or
non-existent, or existing posts cannot provide the service. This does not refer to mere
holiday or sickness absence, or less than 67% attendance, and it refers only to the core
member roles listed in the measure, not to additional roles that the MDT has decided
locally to include as core members, e.g. from the list in the 'extended MDT' measure. The
reviewers should identify the particular missing roles and identify the particular MDT in the
report.
Named Clinical Oncologist
11-2J-102
Compliance:
The core team specific to the MDT should include a consultant clinical oncologist
The named clinical oncologist, agreed by the lead clinician of the MDT.
The responsibility, for review purposes, for the subsequent measures lies with the lead clinician of the MDT.
Level 2 Practitioners for Psychological Support
11-2J-103
At least one clinical core member of the team should have completed the training
necessary to enable them to practice at level 2 for the psychological support of cancer
patients and carers.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the list in the MDT structure measure for core membership.
• The relevant discipline include medical, surgical, nursing and allied health
professionals.
• If the MDT has one or more clinical core members who are trained to level 3 or 4,
the team is deemed to be automatically compliant with this measure.
• The definition of the levels may be found in appendix 1 of the Psychological Support
measures.
Compliance:
The named member. Written confirmation of completion of training agreed by the lead
clinician of the MDT.
Support for Level 2 Practitioners
11-2J-104
Compliance:
SKIN SPECIFIC MEASURES
The level 2 practitioner(s) should receive a minimum of 1 hours clinical supervision by a
level 3 or level 4 practitioner per month.
Reviewers should enquire to ascertain that this is taking place.
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Team Attendance at NSSG Meetings
11-2J-105
Compliance:
The lead clinician of the MDT or representative should attend at least two thirds of the
NSSG meetings.
The attendance record of the NSSG.
MDT Meeting
11-2J-106
The team should hold its meetings at least fortnightly, record core members' attendance
and have a written procedure governing how to deal with referrals which need a
treatment planning decision before the next scheduled meeting.
(Guidance only - e.g. letters, emails or phone calls between certain specified members,
retrospective discussion at the next scheduled meeting).
Compliance:
Attendance records of the meetings.
Written procedure agreed by the lead clinician of the MDT.
MDT Agreed Cover Arrangements for Core Members
11-2J-107
The MDT should agree named cover arrangements for each core member.
Notes:
• This refers to the nominating of staff who should in general be expected to provide
cover for the core members e.g. a specialist trainee on a consultant's team or core
members of the same discipline providing cover for each other. It does not refer to
the member having to provide a person to cover for each and every absence. This
aspect is dealt with by the attendance measure below.
• Where a medical specialty is referred to the cover for a core member need not be a
consultant, but should be a specialist trainee or non-consultant career grade.
• This does not apply to community skin cancer clinician who instead are subject to
measures 11-2J-119, 11-2J-120 and 11-6A-103 nor does it apply to doctors in
primary care performing excision biopsies on supposedly benign lesions.
Compliance:
Written arrangements agreed by the lead clinician of the MDT.
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-108
Core members or their arranged cover (see 11-2J-101 and 11-2J-107) should attend at
least two thirds of the number of meetings.
Note:
This does not apply to community skin cancer clinicians nor does it apply to doctors in
primary care performing excision biopsies on supposedly benign lesions.
Compliance:
Attendance record of the MDT.
The reviewers should identify the particular roles where attendance is below the
requirements of this measure.
Note:
The intention is that core members of the team should be personally committed to it,
reflected in their personal attendance at a substantial proportion of meetings, not relying
instead on their cover arrangements. Reviewers should use their judgement on this matter
and should highlight in their report where this commitment is lacking.
OPERATIONAL POLICIES
Annual Meeting to Discuss Operational Policy
11-2J-109
Compliance:
SKIN SPECIFIC MEASURES
Besides the regular meetings to discuss individual patients, the team should meet at
least annually to discuss, review, agree and record at least some operational policies.
Confirmation of at least one meeting agreed by the lead clinician of the MDT to illustrate
the recording of at least some operational policies.
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
Bi-annual Educational/Audit Meetings
11-2J-110
The MDT should take part in at least two meetings per year which fulfil the following:
• the authorised clinicians practising in the community and associated with the MDT
are invited to attend;
• the progress and/or results of the network skin cancer audit (as specified in measure
11-1C-104j) are discussed;
• teaching is given on aspects of skin cancer management.
Notes:
• There may be more than two such meetings per year.
• The MDT may combine with other skin cancer MDTs for this purpose, e.g. a
network-wide meeting.
• The meeting may be used for other purposes, additional to those specified in this
measure.
Compliance:
Confirmation of two such meetings in the last 12 months sufficient to show compliance.
Note:
The reviewers should enquire as to whether community practitioners were invited.
Policy for All New Patients Specified as Level 4, 5 or 6 Care to be Reviewed by MDT
11-2J-111
There should be an operational policy for the team whereby it is intended that new skin
cancer patients, as listed below, will be reviewed by the multidisciplinary team for
discussion of initial treatment plan.
The cases for individual MDT review should include those cases specified as 'level 4'
care and 'level 5 and 6' care. Those at levels 5 and 6 may be referred on straight after
diagnosis to SSMDTs or a supranetwork team as relevant with retrospective review by
the LSMDT.
The policy should specify at what other stages in the patient pathway patients are
referred back for discussion.
Notes:
• For the arrangements for those cases which need not be formally, individually
reviewed, see 'when is a patient, a patient' in the introduction to the skin cancer
measures.
Compliance:
The operational policy agreed by the lead clinician of the MDT.
Policy for Communication of Diagnosis to GPs
11-2J-112
The MDT should have agreed a policy whereby after a patient is given a diagnosis of
cancer, the patient's general practitioner (GP) is informed of the diagnosis by the end of
the following working day.
The MDT should have completed an audit against this policy of the timeliness of
notification to GPs of the diagnosis of cancer.
Compliance:
The written policy agreed by the lead clinician of the MDT.
The written results of the audit.
Operational Policy for Named Key Worker
11-2J-113
There should be an operational policy whereby a single named key worker for the
patient's care at a given time is identified by the MDT for each individual patient and the
name and contact number of the current key worker is recorded in the patient's case
notes. The responsibility for ensuring that the key worker is identified should be that of
the nurse MDT member(s).
The above policy should have been implemented for patients who came under the MDTs
care after publication of these measures and who are under their care at the time of the
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peer review visit.
Notes:
• For information: according to the NICE supportive and palliative care guidance, a
key worker is a person who, with the patient's consent and agreement, takes a key
role in co-ordinating the patient's care and promoting continuity e.g. ensuring the
patient knows who to access for information and advice. This is not intended to have
the same connotation as the key worker in social work.
• It may be necessary to agree a single key worker across both a cancer site specific
MDT and the specialist palliative care MDT for certain patients.
Compliance:
The written policy agreed by the lead clinician of the MDT.
Reviewers should spot check some of the relevant patients' case notes.
Core Histopathology Member Taking Part in Histopathology EQA
11-2J-114
The core histopathology members of the MDT should be taking part in a general
histopathology EQA that includes skin pathology.
Note:
They may be taking part in the national specialist dermatopathology EQA, in which case,
this confers compliance with the above requirement.
Compliance:
Documentary evidence to show they are taking part in the EQA.
Note:
Their actual performance against the requirements of the EQA is not subject to peer
review.
MDT NURSE SPECIALIST MEASURES
Introduction
Why are there currently "nursing measures" for MDTs, but no similar requirements for other MDT
members?
The modern change to MDT working has created and then highly developed the specific role of nurse MDT
member with its related activities which, in full measure, go to make up the role of cancer nurse specialist.
The roles of the medical specialties in the MDT have not been so profoundly influenced or so extensively
developed by their MDT membership itself compared to that of the MDT nurse specialist. The role
definitions and training requirements of nurse MDT members are not very well established "officially"
outside the MDT world in contrast to the well defined medical specialties with their formal national training
requirements (e.g. there were dermatologists and palliative care physicians before there were established
skin MDTs and specialist palliative care teams). Therefore a particularly strong need was perceived for
using the measures to define more clearly the role of the nurse specialist and to set out minimum training
requirements for nursing input into MDTs. This is in order to establish these roles more firmly in the NHS
infrastructure and to avoid the situation where MDTs can comply with measures by having generalist nurses
who "sit in" on MDT meetings and sign attendance forms but play no defining role in the team's actual
dealings with its patients.
Core Nurse Members Completed Specialist Study
11-2J-115
Compliance:
Each core nurse specialist should have successfully completed a programme of study in
their specialist area of nursing practice, which has been accredited for at least 20 credits
at 1st degree level or equivalent.
Confirmation of successful completion of the course/module.
Agreed Responsibilities for Core Nurse Members
11-2J-116
The MDT should have agreed a list of responsibilities, with each of the core nurse
specialists of the team, which includes the following:
• contributing to the multidisciplinary discussion and patient assessment/care planning
decision of the team at their regular meetings;
• providing expert nursing advice and support to other health professionals in the
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
•
•
•
•
•
nurse's specialist area of practice;
involvement in clinical audit;
leading on patient and carer communication issues and co-ordination of the patient
pathway for patients referred to the team - acting as the key worker or responsible
for nominating the key worker for the patient's dealings with the team.
ensuring that results of patients' holistic needs assessment are taken into account in
the decision making
contributing to the management of the service (see note below);
utilising research in the nurse's specialist area of practice.
Notes:
• "Management" in this context does not mean clerical tasks involving the
documentation on individual patients i.e. this responsibility does not overlap with the
responsibility of the MDT co-ordinator.
• A list of responsibilities containing all the elements in this measure and the previous
measure would encompass all of the four domains of specialist practice required for
the role of cancer nurse specialist.
• Additional responsibilities may be agreed.
Compliance:
The list of responsibilities agreed by the lead clinician of the MDT and the core nurse
specialist(s).
Attendance at National Advanced Communications Skills Training Programme
11-2J-117
At least those core member of the team who have direct clinical contact with patients
should have attended the national advanced communications skills training.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the list in the MDT structure measure for core membership.
• Also, it applies only with regard to members which are in place i.e. if a team lacks a
given core member from that list, it should still be counted as compliant with this
measure provided those members which are in place comply.
• The relevant disciplines include medical, surgical, nursing and allied health
professionals.
• The reviewers should record which core members of those relevant are non
compliant.
Compliance:
SKIN SPECIFIC MEASURES
Written confirmation of the MDT members who have attended the national advanced
communications skills training programme.
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Extended Membership of MDT
11-2J-118
The MDT should provide the names of members of the extended team for named roles
in the team, if they are not already offered as core team members.
The named extended team for the LSMDT should include:
• surgeon, who is a core member of a SSMDT;
Note: If the LSMDT does not have a core member who is a consultant surgeon, it should
name a surgical core member of the SSMDT to which it refers patients for level 5 care,
as a member of the extended team for the LSMDT.
• clinical oncologist;
• medical oncologist.
Note: As with the case of the surgeon, the oncologists should be core members of the
SSMDT.
•
•
•
•
•
•
•
•
•
Compliance:
a core member of the specialist palliative care team;
clinical psychologist/person agreed as able to provide counselling;
a person agreed as able to provide advice on cosmetic camouflage;
clinical geneticist/person agreed as able to provide genetic counselling;
occupational therapist;
person agreed as contact point for prosthetic service;
person agreed as contact point for orthotics service;
physiotherapist;
person agreed as contact point for lymphoedema service.
Name of each extended team member with their role agreed by the lead clinician of the
MDT.
CLINICAL GOVERNANCE OF COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-2J-119
TRAINING FOR MODEL 2 COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-2J-120
This measure has been withdrawn
11-2J-121
PROVIDING PATIENT CENTRED CARE
Patient Permanent Consultation Record
11-2J-122
The MDT should be offering patients the opportunity of a permanent record or summary
of at least a consultation between the patient and the doctor when the following are
discussed:
• diagnosis;
• treatment options and plan;
• relevant follow up (discharge) arrangements.
Note:
The MDT may, in addition, offer a permanent record of consultations undertaken at other
stages of the patient's journey.
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The record of consultation should identify areas discussed during consultation and
include a diagram where appropriate which supports the consultation discussion.
The consultation record provides a permanent summary of the discussion between the
doctor and the patient and should always be offered to the patient unless specifically
declined by the patient;
A record should be kept in the notes
Compliance:
The reviewers should enquire of the working practice of the team and see anonymised
examples of records given to patients.
Note:
It is recommended that they are available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
Patient Experience Exercise
11-2J-123
The MDT should have undertaken or be undertaking an exercise during the previous two
years prior to review or completed self-assessment to obtain feedback on patients'
experience of the services offered.
The exercise should at least ascertain whether patients were offered:
• a key worker;
• assessment of their physical, emotional, practical, psychological and spiritual needs
(holistic needs assessment);
• the MDTs information for patients and carers (written or otherwise);
• the opportunity of a permanent record or summary of a consultation at which their
treatment options were discussed.
Notes:
• The exercise may consist of a survey, questionnaire, focus group or other method.
• There may be additional items in the exercise. It is recommended that other aspects
of patient experience are covered.
The exercise should have been presented and discussed at an MDT meeting and the
team should have implemented at least one action point arising from the exercise.
Compliance:
The results (complete or in progress) of the exercise.
A report for the action taken.
Provision of Written Patient Information
11-2J-124
The MDT should provide written material for patients and carers which includes:
• information specific to that MDT about local provision of the services offering the
treatment for that cancer site;
• information about patient involvement groups and patient self-help groups;
• information about the services offering psychological, social and spiritual/cultural
support, if available;
• information specific to the MDT's cancer site or group of cancers about the disease
and its treatment options (including names and functions/roles of the team treating
them);
• information about services available to support the effects of living with cancer and
dealing with its emotional effects.
It is recommended that the information and its delivery to patients and carers follow the
principles of the NHS Information Prescription project.
(www.informationprescription.info).
Notes:
• The information prescription should be tailored to the patients/carers needs based
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on an information needs assessment. Information may be generated and dispensed
outside of the clinic environments within an information centre where a clear
operational policy between the clinic and information centre is in place which
identifies how clinic records are updated and that facilities and resources within the
information centre are appropriate to providing such a service.
• The information prescription should be composed of information from the national
pathways supplemented with national and local accredited information.
Compliance:
The written (visual and audio if used - see note below) material.
Notes:
It is recommended that it is available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
For purposes of self-assessment the team should confirm the written information which is
routinely offered to patients.
TREATMENT PLANNING DECISION
Agree and Record Individual Patient Treatment Plans
11-2J-125
The core MDT at their regular meetings should agree and record individual patient's
treatment plans. A record is made of the treatment plan. The record should include:
• the identity of patients discussed;
• the multidisciplinary treatment planning decision (i.e. to which modalities of
treatment, surgery, radiotherapy, chemotherapy, biological therapy, supportive care
or a combination of the same, the case is to be referred for consideration);
• in the case of patients referred to a SSMDT, MMDT or supranetwork team for care
levels 5 or 6, the team to which they are referred should be named.
Note:
A therapeutic operation may in effect form part of the initial investigation and staging
procedure to render the patient suitable for discussion and for subsequent treatment
planning decision. This operation should be recorded.
Compliance:
Anonymised examples of the record of a meeting and individual anonymised treatment
plans of individuals.
Notes:
Only exactly what is required in the list above is necessary for evidence. Detailed minutes
of the content of discussions over patients are not required for evidence.
For peer review purposes, patient specific information should be anonymised.
It is recommended that this essential information is recorded on an MDT decision
proforma as well as in individual patient's notes.
NETWORK GUIDELINES
Referral Guidelines Between Teams
Introduction
In view of:
i) the various possible configurations for the MDTs;
ii) the need to have agreed the particular configuration for the whole network.
The responsibility for review purposes for referral guidelines between LSMDTs, SSMDTs, MMDTS where
relevant and supranetwork teams lies with the lead clinician of the MDT, the chair of the NSSG and the
Chair of the Network Board.
Network Referral Guidelines Between Named Teams
11-2J-126
SKIN SPECIFIC MEASURES
The LSMDT should agree referral guidelines compatible with the network board's referral
guidelines between teams (topic 11-1A, measure 11-1A-207j). The LSMDT's guidelines
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should include the following:
• that patients who need level 5 care (as specified in the introduction to the skin
cancer measures) are referred to a named SSMDT (or MMDT if relevant);
• that patients who need level 6 care (as specified in the introduction to skin cancer
measures) are referred to the relevant named supranetwork team, or photopheresis
facility.
Compliance:
The referral guidelines, naming the MDTs and their host hospitals agreed by the lead
clinician of the LSMDT, the Chair of the NSSG and the Chair of the Network Board.
Notes:
The LSMDT may refer patients to a team in another network if compatible with the host
network's guidelines.
Patients for level 6 care may be referred direct to the supranetwork team or via an
SSMDT depending on circumstances.
CLINICAL GUIDELINES
Introduction
Clinical guidelines refer to how a given patient should be clinically managed by which modality(ies) of
treatment (surgery, radiotherapy, chemotherapy, biological therapy) rather than detailed chemotherapy
regimens and techniques of surgery or radiotherapy. More details of regimens and techniques may be
agreed if desired but they are covered elsewhere in the measures. Because there may not be any
comprehensive national consensus at the level of clinical guidelines, compliance with the measure does not
depend on reviewers' judgement on the details of their contents, although they may comment in their report.
Similar considerations apply to imaging and pathology guidelines (see below). In the case of the IOG for
skin cancer, the area of clinical guidelines overlaps to a degree with the descriptions of the particular groups
of patients which are subject to the different levels of care.
The responsibility for review purposes for clinical guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs, should produce the agreed
network-wide clinical guidelines. The individual MDT for their compliance with this measure, should agree to
abide by them.
MDT Agreement to Clinical Guidelines for the Management of Skin Cancer
11-2J-127
Compliance:
The MDT should agree specified network-wide clinical guidelines with the NSSG. Where
there are agreed national clinical guidelines, the network and the MDT should accept
those.
The network guidelines agreed by the lead clinician of the MDT and the Chair of the
NSSG.
IMAGING GUIDELINES
Introduction
The responsibility for review purposes for imaging guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
imaging group, should produce the network-wide imaging guidelines. The individual MDT for their
compliance with this measure, should agree to them.
MDT Agreement to Imaging Guidelines
11-2J-128
Compliance:
SKIN SPECIFIC MEASURES
The MDT should agree imaging guidelines for the diagnosis and assessment of skin
cancer.
The network imaging guidelines agreed by the lead clinician of the MDT and Chair of the
NSSG.
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PATHOLOGY GUIDELINES
Introduction
The responsibility for review purposes for pathology guidelines lies with the lead clinician of the MDT and
the Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
pathology group, should produce the network-wide pathology guidelines. The individual MDT for their
compliance with this measure, should agree to them.
MDT Agreement to Pathology Guidelines
11-2J-129
Compliance:
The MDT should agree pathology guidelines for the diagnosis and assessment of skin
cancer.
The network pathology guidelines agreed by the lead clinician of the MDT and Chair of
the NSSG.
DATA COLLECTION
Agreed Collection of Minimum Dataset
11-2J-130
The MDT should agree the same minimum dataset (MDS) with other MDTs of the same
cancer site(s) across the network (network-wide MDS). The MDS should include the data
items required for:
• the cancer waiting times monitoring, including Going Further on Cancer Waits in
accordance with DSCN 20/2008, to the specified timetable as specified in the
National Contract for Acute Services;
• the Cancer Registration Dataset as specified in the National Contract for Acute
Services.
The MDS must include all items required for the national contract, any additional items
should use definitions and codes taken from National Cancer Dataset and the NHS Data
Dictionary.
Notes:
• The network MDS may include additional data items.
The MDT should have started to record the MDS or their portion of the MDS for each
patient on proformas and/or in an electronically retrievable form.
Compliance:
The MDS agreed by the lead clinician of the MDT and the Chair of the NSSG.
Note:
For compliance, the NSSG should produce the agreed MDS and the individual MDT for
their compliance with this measure, should agree to collect it.
Anonymised record of data for individual patients.
Note:
For the purpose of self-assessment the team should confirm that they started to record
the MDS in compliance with the details of the measure.
NETWORK AUDIT
Introductory Notes
For review purposes a network audit project is an audit project related to the cancer site or sites of the
NSSG and the activities of its MDTs. The same project should be carried out by all MDTs for that cancer
site in the network, each team's results being separately identified. The individual MDTs, for compliance
with their relevant MDT measure, should agree to participate in the audit. see appendix 1 for audit.
Network Audit
11-2J-131
The MDT should agree to participate in the network audit project agreed by the NSSG.
The MDT should annually review the progress of the project or present the results of the
completed network audit project to the NSSG for discussion at one of their meetings.
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Notes:
For MDTs which have previously been peer reviewed the project should have been
completed since that previous peer review.
Compliance:
The audit agreed by the lead clinician of the MDT and the Chair of the NSSG.
Written confirmation of review of progress of audit sufficient to show compliance with the
measure.
Discussion of Clinical Trials
11-2J-132
The MDT should produce a report at least annually on clinical trials, for discussion with
the NSSG. The report should include;
• Details of the MDT's trials portfolio including the extent of local provision of the
national portfolio.
• The MDT's recruitment to the portfolio, including the extent of delivery against the
locally agreed timescales and targets.
• The MDT's programme for improvement for the above, as proposed to the NSSG.
The MDT should agree a final programme for improvement at the NSSG discussion
meeting.
Note:
For compliance with this measure the MDT should produce a proposed programme for
improvement and, at the discussion with the NSSG, settle on a mutually agreed
programme between the participants of the meeting.
In addition, applicable only to MDTs dealing with the following cancer sites:
•
•
•
•
•
•
Leukaemia
Lymphoma
Germ cell malignancy
Bone and/or soft tissue sarcoma
Brain and CNS malignancy
Malignant melanoma
The MDT should produce a report on clinical trials, covering the above points, for TYA
patients, for discussion with the teenage and young adults' cancer network
co-coordinating group (TYACNCG).
The MDT should agree a final programme for improvement for TYA clinical trials with the
TYACNCG.
Note:
The TYACNCG's current list of trials and studies suitable for TYAs may not include any
of those malignancies dealt with by the MDT under review, in which case this is not
applicable for the current assessment in question.
Compliance:
The report, agreed by the lead clinician of the MDT. The reviewers should check that the
contents fulfil the points above.
The programme for improvement, agreed by the lead clinician of the MDT and the clinical
lead for the cancer research network.
Where relevant, the clinical trials report for TYA patients, agreed by the lead clinician of
the MDT, and the programme for improvement agreed by the lead clinician of the MDT,
the Chair of the TYACNCG and the clinical lead for the cancer research network.
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MDT WORKLOAD
A minimum viable workload is not directly dealt with in the measures for the LSMDT but is covered indirectly
by the requirement that the LSMDT should be the only skin cancer MDT in its host hospital.
OPERATIONAL POLICIES REGARDING THE MDT LEAD CLINICIAN COMMUNITY SKIN CANCER
SERVICE
Measure 11-2J-133 applies only to an MDT which has associated community skin cancer clinicians
(declared in measure 11-2J-119)
This measure has been withdrawn
11-2J-133
This measure has been withdrawn
11-2J-134
Joint Treatment Planning for TYAs
11-2J-135
For each patient in the TYA age group, the MDT should agree the following decisions
with the TYA MDT and record them as part of that patient's joint treatment planning
decision:
• the multidisciplinary treatment planning decision (i.e. to which modality(s) of
treatment-surgery, radiotherapy, chemotherapy, biological therapy or supportive
care, or combinations of the same, they are to be referred to for consideration);
• the named consultant in charge of each modality of definitive treatment and the
named person in charge of organising arrangements for the age-appropriate support
and care environment including those when the treatment is delivered outside the
PTC facility.
For those in the age range 19 to the end of their 24th birthday, the MDT should record
the choice of treatment location, made by the patient, in particular, whether it is the TYA
facility or which of the named designated hospitals for TYAs.
Notes:
Patients in the age range 16 to the end of their 18th birthday should be treated in the
PTC.
The date of joint agreement to the planning and of the patient's choice of treatment place
may be later than the date of the initial treatment planning discussion by the MDT.
Compliance:
The reviewers should ask to see examples of the treatment planning decision record of
patients from the TYA age group. Evidence of joint agreement should be by individual
TYA patient decision records of the site-specific MDT being authorised by a core member
of the TYA MDT.
Note:
If the MDT has had no such patients referred since the last assessment/review this part of
the measure is considered to have been complied with. The overall compliance depends
then, only on the non-TYA aspects of this measure.
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TOPIC 11-2J-2 - SPECIALIST SKIN MULTIDISCIPLINARY TEAM (SSMDT)
When is a Team a Team and When is it not a Team?
The measures review a variety of aspects of the team, both structure and function, but the key question,
which underlies all this, is who exactly constitutes the MDT, from the point of view of the peer review? Which
group of people should be put forward for review against these measures, and that is it who is held compliant
or not compliant? This is best answered from the patient's point of view. If you were a patient who would you
consider to be your MDT? Primarily it is that group of people of different health care disciplines which meets
together at a given time (whether physically in one place, or by video or tele-conferencing) to discuss a given
patient and who are each able to contribute independently to the diagnostic and treatment decisions about the
patient. They constitute that patient's MDT.
The way the MDT meeting itself is organised is left to local discretion such that different professional
disciplines may make their contributions at different times, without necessarily being present for the whole
meeting in order to prevent wastage of staff time. The key requirement is that each discipline is able to
contribute independently to the decisions regarding each relevant patient. For some cancer types the IOG has
laid down detailed requirements over how the diagnostic process should be incorporated into the MDT system
and this has also been translated into the measures where applicable.
Two or more groups of people who may have declared an alliance to form a so-called 'combined' MDT but
who do not all meet together to collectively contribute to the decisions on a given patient, as specified above,
do not constitute an MDT from the point of view of peer review. Such alliances have been attempted in order
to achieve, for instance, a minimum caseload or catchment population. This is not appropriate. Each separate
group, meeting as specified above, should be assessed separately against such criteria.
In general the measures should be applied to that defined group, but there are some functions for which
MDTs may combine in a way which is appropriate. Then, the evidence put forward to demonstrate their
compliance with the relevant measures may serve as common evidence across the MDTs but it is applied
separately and compliance is awarded separately to each team.
The main examples of this are as follows:
• a combined operational policy meeting but the policies are agreed on behalf of each MDT by its lead
clinician;
• network-wide clinical, referral, imaging and pathology guidelines, but each MDT agrees to abide by them;
• the same network-wide project for network audit, but each MDT agreeing to participate;
• a common minimum dataset, but each MDT agrees to collect its portion of it;
• a network list of approved trials but each MDT agrees to enter patients;
• an individual health professional being a member of more than one MDT, but a particular defined and
named set of people make up a given MDT.
As well as meeting to make the combined multidisciplinary decisions about patients, the members of some
types of MDTs are required by the measures to carry out another key function in company with other specified
personnel. Thus, some of the more complex surgical procedures should all be performed by the same group
of professionals - surgeon, anaesthetist and skilled theatre and aftercare staff. This is ensured by requiring
services to be organised for that MDT so that all cases of a given procedure are performed in the same
hospital. The people will largely be a different set of people from those who meet to make the diagnostic and
treatment decisions (the MDT as defined in the measures)
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but they will directly relate to that MDT and be specified by it, because at least one key functionary, the
surgeon, will be a core member of that MDT.
In requiring all the complex procedures to be performed in the same hospital of the MDT ties in the referral
catchment population of the MDT to that hospital. This provides a direct link between the referring catchment
population for MDT discussion and the treatment caseload of the treating team and its hospital facilities.
When is a Patient, a Patient and When are they not a Patient?
In the case of LSMDTs (and SSMDTs acting in their role of LSMDT to their local catchment), where the
wording of a measure refers to patients, for the purpose of peer review, applies only to those patients whose
case is subject to formal, individual MDT discussion, unless stated otherwise.
The requirements for the large group of patients who are dealt with by authorised clinicians in the community
or by hospital based MDT members, but without individual MDT discussion (level 3 care, see introduction to
the skin cancer measures), are met by the measures concerned with quality assurance of community practice
and the skin cancer network audit.
MDTs may wish to extend various aspects of their working practices, as specified in the measures, to this
group of patients (e.g. patient written information). This is at their discretion and is largely to be encouraged
but it will not affect their compliance with the measures.
MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
The responsibility, for review purposes, for measure 11-2J-201 lies with the lead clinician of the host trust
(see topic 11-1A)
MDT STRUCTURE
Lead Clinician and Core Team Membership
11-2J-201
There should be a single named lead clinician for the named MDT who should then be a
core team member.
The lead clinician of the MDT should have agreed the responsibilities of the position with
the lead clinician of the host trust.
Note:
The role of lead clinician of the MDT should not of itself imply chronological seniority,
superior experience or superior clinical ability.
The MDT should provide the names of core team members for named roles in the team.
The core team specific to the LSMDT should include:two dermatologists;
• two dermatologists;
• two surgeons, at least one of whom should be a consultant surgeon trained in plastic
and reconstructive surgery;
• skin nurse specialist;
• two histopathologists;
• imaging specialist;
• clinical oncologist;
• medical oncologist;
• MDT co-ordinator/secretary;
• a NHS-employed member of the core or extended team should be nominated as
having specific responsibility for users' issues and information for patients and
carers;
• a member of the core team nominated as the person responsible for ensuring that
recruitment into clinical trials and other well designed studies is integrated into the
function of the MDT
Notes:
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• Each clinical core member should have sessions specified in the job plan for the
care of patients with skin cancer and attendance at MDT meetings.
• Where a medical specialty is referred to, the core team member should be a
consultant. The cover for this member need not be a consultant. Where a medical
skill rather than a specialty is referred to this may be provided by one or more of the
core members or by a career grade non-consultant medical staff member.
• The co-ordinator/secretary role needs different amounts of time depending on team
workload. See appendix 2 for an illustration of the responsibilities of this role. The
co-ordinator and secretarial role may be filled by two different named individuals or
the same one. It need not occupy the whole of an individual's job description.
• There may be additional core members agreed for the team besides those listed
above.
• For a SSMDT sharing its catchment population with that of a MMDT: The level 5
care for malignant melanoma should be referred to the MMDT and the SSMDT need
not have a medical oncologist as a core member (although they may choose to), but
if there is no medical oncology core member, there should be one as a member of
the extended team (see measure on the extended MDT).
Compliance:
Named lead clinician for the MDT agreed by the lead clinician of the host trust.
The written responsibilities agreed by the lead clinician of the MDT and lead clinician of
the host trust.
Note:
See appendix 2 for an illustration of the responsibilities of this role.
Name of each core team member with their role, agreed by the lead clinician of the host
trust.
Notes:
The reviewers should record in their assessment each case where the post(s) needed to
provide the minimum core membership for a given listed role in the measure is unfilled or
non-existent, or existing posts cannot provide the service. This does not refer to mere
holiday or sickness absence, or less than 67% attendance, and it refers only to the core
member roles listed in the measure, not to additional roles that the MDT has decided
locally to include as core members, e.g. from the list in the 'extended MDT' measure. The
reviewers should identify the particular missing roles and identify the particular MDT in the
report.
The responsibility, for review purposes, for the subsequent measures lies with the lead clinician of the MDT.
Level 2 Practitioners for Psychological Support
11-2J-202
At least one clinical core member of the team should have completed the training
necessary to enable them to practice at level 2 for the psychological support of cancer
patients and carers.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the list in the MDT structure measure for core membership.
• The relevant discipline include medical, surgical, nursing and allied health
professionals.
• If the MDT has one or more clinical core members who are trained to level 3 or 4,
the team is deemed to be automatically compliant with this measure.
• The definition of the levels may be found in appendix 1 of the Psychological Support
measures.
Compliance:
The named member.
Written confirmation of completion of training agreed by the lead clinician of the MDT.
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Support for Level 2 Practitioners
11-2J-203
Compliance:
The level 2 practitioner(s) should receive a minimum of 1 hours clinical supervision by a
level 3 or level 4 practitioner per month.
Reviewers should enquire to ascertain that this is taking place.
Team Attendance at NSSG Meetings
11-2J-204
Compliance:
The lead clinician of the MDT or representative should attend at least two thirds of the
NSSG meetings.
The attendance record of the NSSG.
MDT MEETINGS
MDT Meeting
11-2J-205
The team should hold its meetings at least fortnightly, record core members' attendance
and have a written procedure governing how to deal with referrals which need a
treatment planning decision before the next scheduled meeting.
(Guidance only - e.g. letters, emails or phone calls between certain specified members,
retrospective discussion at the next scheduled meeting).
Compliance:
Attendance records of the meetings.
Written procedure agreed by the lead clinician of the MDT.
MDT Agreed Cover Arrangements for Core Members
11-2J-206
The MDT should agree named cover arrangements for each core member.
Notes:
• This refers to the nominating of staff who should in general be expected to provide
cover for the core members e.g. a specialist trainee on a consultant's team or core
members of the same discipline providing cover for each other. It does not refer to
the member having to provide a person to cover for each and every absence. This
aspect is dealt with by the attendance measure below.
• Where a medical specialty is referred to the cover for a core member need not be a
consultant, but should be a specialist trainee or non-consultant career grade.
• This does not apply to community skin cancer clinicians who instead are subject to
measures 11-2J-221, 11-2J-222 and 11-6A-103 nor does it apply to doctors in
primary care performing excision biopsies on supposedly benign lesions.
Compliance:
Written arrangements agreed by the lead clinician of the MDT.
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-207
Core members or their arranged cover (see 11-2J-201 and 11-2J-206) should attend at
least two thirds of the number of meetings.
Note:
This does not apply to community skin cancer clinicians who instead are subject to
measures 11-2J-221, 11-2J-222 and 11-6A-103 nor does it apply to doctors in primary
care performing excision biopsies on supposedly benign lesions.
Compliance:
Attendance record of the MDT.
The reviewers should identify the particular roles where attendance is below the
requirements of this measure.
Note:
The intention is that core members of the team should be personally committed to it,
reflected in their personal attendance at a substantial proportion of meetings, not relying
instead on their cover arrangements. Reviewers should use their judgement on this matter
and should highlight in their report where this commitment is lacking.
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OPERATIONAL POLICIES
Annual Meeting to Discuss Operational Policy
11-2J-208
Compliance:
Besides the regular meetings to discuss individual patients, the team should meet at
least annually to discuss, review, agree and record at least some operational policies.
Confirmation of at least one meeting agreed by the lead clinician of the MDT to illustrate
the recording of at least some operational policies and evidenced in annual report.
Bi-annual Educational/Audit Meetings
11-2J-209
The MDT should take part in at least two meetings per year which fulfil the following:
i) the authorised clinicians practising in the community and associated with the MDT are
invited to attend;
ii) the progress and/or results of the network skin cancer audit (as specified in measure
11-1C-104j) are discussed;
iii) teaching is given on aspects of skin cancer management.
Notes:
• There may be more than two such meetings per year.
• The MDT may combine with other skin cancer MDTs for this purpose, e.g. a
network-wide meeting.
• The meeting may be used for other purposes, additional to those specified in this
measure.
Compliance:
Confirmation of two such meetings in the last 12 months sufficient to show compliance.
Note:
The reviewers should enquire as to whether community practitioners were invited.
Policy for all New Patients Specified as Level 4, 5 or 6 Care to be Reviewed by MDT
11-2J-210
There should be an operational policy for the team whereby it is intended that new skin
cancer patients, as listed below, will be reviewed by the multidisciplinary team for
discussion of initial treatment plan.
The cases for individual MDT review should include those cases specified as 'level 4'
care (where the SSMDT is acting as its own local LSMDT) and 'level 5 and 6' care.
Those at level 6 may be referred on straight after diagnosis to a supranetwork team with
retrospective review by the SSMDT.
The policy should specify at what other stages in the patient pathway patients are
referred back for discussion.
Notes:
For the arrangements for those cases which need not be formally, individually reviewed,
see 'when is a patient a patient' in the introduction to the skin cancer measures.
Compliance:
The operational policy agreed by the lead clinician of the MDT.
SPECIALIST TEAMS FUNCTIONING AS A LOCAL TEAM
Introduction
The following measure refers to the specialist team's functions as a local team for its local population.
Policy for Communication of Diagnosis to GPs
11-2J-211
The MDT should have agreed a policy whereby after a patient is given a diagnosis of
cancer the patient's general practitioner (GP) is informed of the diagnosis by the end of
the following working day.
The MDT should have completed an audit against this policy of the timeliness of
notification to GPs of the diagnosis of cancer.
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Compliance:
The written policy agreed by the lead clinician of the MDT.
The written results of the audit.
Specific Procedures Carried Out in Same Named Hospital
11-2J-212
The following procedures carried out by the members of the SSMDT, together with their
acute post operative care, should each take place in the same named hospital, e.g. all
block lymph node dissections should be carried out in the same hospital, and all limb
perfusion in same hospital, but the hospital for block lymph node dissections need not be
the hospital for limb perfusions.
•
•
•
•
•
•
Compliance:
block lymph node dissections;
sentinel node biopsy;
metastatectomy/debulking for recurrent melanoma;
isolated limb perfusion;
isolated limb infusion;
reconstruction procedures involving microvascular surgical techniques.
The reviewers should enquire as to the team's working arrangements.
Notes:
For the purpose of self-assessment a list of the procedures and which hospital should be
included in the annual report.
There may be different hospitals for different procedures but all cases of each individual
procedure of the MDT on the list should be carried out in one hospital.
Individual Surgical Member Inguinal or Axillary Dissections Workload
11-2J-213
Each individual core surgical member of the SSMDT who performs inguinal or axillary
lymph node dissections on the MDT's patients should fulfil the following with regards to
those patients:
• The summed total number of groin plus axillary dissections per year should be 15 or
more.
Notes:
• Only dissections performed for skin cancer count towards the total.
• The total of 15 may consist of entirely inguinal or entirely axillary or a combination of
both types of procedure.
• The total should be averaged over the two most recent complete calendar years
prior to the peer review visit or completed self-assessment.
• For a lymph node dissection to count towards the total the surgeon should have
been present and scrubbed at the procedure as evidenced by their being named as
a participating surgeon in the operation notes.
• This measure does not apply to neck node dissections.
Compliance:
The named members, each with their individual totals.
Operational Policy for Named Key Worker
11-2J-214
There should be an operational policy whereby a single named key worker for the
patient's care at a given time is identified by the MDT for each individual patient and the
name and contact number of the current key worker is recorded in the patient's case
notes. The responsibility for ensuring that the key worker is identified should be that of
the nurse MDT member(s).
The above policy should have been implemented for patients who came under the
MDT's care after publication of these measures and who are under their care at the time
of the peer review visit.
Notes:
• For information: according to the NICE supportive and palliative care guidance a key
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worker is a person who, with the patient's consent and agreement, takes a key role
in co-ordinating the patient's care and promoting continuity e.g. ensuring the patient
knows who to access for information and advice. This is not intended to have the
same connotation as the key worker in social work.
• It may be necessary to agree a single key worker across both a cancer site specific
MDT and the specialist palliative care MDT for certain patients.
Compliance:
The written policy agreed by the lead clinician of the MDT.
Reviewers should spot check some of the relevant patients' case notes.
Core Histopathology Members Taking Part in the National Specialist Dermatopathology EQA
11-2J-215
Compliance:
The core histopathology members of the MDT should be taking part in the national
specialist dermatopathology EQA.
Documentary evidence to show they are taking part in the EQA.
Note:
Their actual performance against the requirements of the EQA is not subject to peer
review.
Introduction
The next measure is applicable only in a network hosting a photopheresis facility which accepts referrals of
cutaneous lymphoma patients, and in particular, to the SSMDT acting as the cutaneous lymphoma MDT for
that network.
Policy for Discussion of Cutaneous Lymphoma Cases Referred for Potential Photopheresis
11-2J-216
Compliance:
There should be an operational policy for the MDT whereby a consultant responsible for
photopheresis should discuss all cutaneous lymphoma cases referred for potential
photopheresis at an MDT meeting prior to treatment.
The policy agreed by the lead clinician of the MDT and a consultant from the staff of the
photopheresis facility.
MDT NURSE SPECIALIST MEASURES
Introduction
Why are there currently "nursing measures" for MDTs but no similar requirements for other MDT members?
The modern change to MDT working has created and then highly developed the specific role of nurse MDT
member with its related activities which, in full measure, go to make up the role of cancer nurse specialist.
The roles of the medical specialties in the MDT have not been so profoundly influenced or so extensively
developed by their MDT membership itself compared to that of the MDT nurse specialist. The role
definitions and training requirements of nurse MDT members are not very well "officially" established
outside the MDT world in contrast to the well defined medical specialties with their formal national training
requirements (e.g. there were dermatologists and palliative care physicians before there were established
skin MDTs and specialist palliative care teams). Therefore a particularly strong need was perceived for
using the measures to define more clearly the role of the nurse specialist and to set out minimum training
requirements for nursing input into MDTs. This is in order to establish these roles more firmly in the NHS
infrastructure to avoid the situation where MDTs can comply with measures by having generalist nurses
who "sit in" on MDT meetings and sign attendance forms but play no defining role in the team's actual
dealings with its patients.
Core Nurse Members Completed Specialist Study
11-2J-217
Compliance:
SKIN SPECIFIC MEASURES
Each core nurse specialist should have successfully completed a programme of study in
their specialist area of nursing practice, which has been accredited for at least 20 credits
at 1st degree level or equivalent.
Confirmation of successful completion of the course/module.
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Agreed Responsibilities for Core Nurse Members
11-2J-218
The MDT should have agreed a list of responsibilities with each of the core nurse
specialists of the team, which includes the following:
• contributing to the multidisciplinary discussion and patient assessment/care planning
decision of the team at their regular meetings;
• providing expert nursing advice and support to other health professionals in the
nurse's specialist area of practice;
• involvement in clinical audit;
• leading on patient and carer communication issues and co-ordination of the patient's
pathway for patients referred to the team - acting as the key worker or responsible
for nominating the key worker for the patient's dealings with the team.
• ensuring that results of patients' holistic needs assessment are taken into account in
the decision making;
• contributing to the management of the service (see note below);
• utilising research in the nurse's specialist area of practice.
Note:
Additional responsibilities to those in this measure and the next measure may be agreed.
Compliance:
The list of responsibilities agreed by the lead clinician of the MDT and the core nurse
specialist(s).
Attendance at National Advanced Communications Skills Training Programme
11-2J-219
At least those core members of the team who have direct clinical contact with patients
should have attended the national advanced communication skills training.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the MDT structure measure for core membership.
• Also, it applies only with regard to members which are in place i.e. if a team lacks a
given core member from that list, it should still be counted as compliant with this
measures provided those members which are in place comply,
• The relevant disciplines include medical, surgical, nursing and allied health
professionals.
• The reviewers should record which core members of those relevant are non
compliant.
Compliance:
Written confirmation of the MDT members who have attended the national advanced
communications skills training programme.
Extended Membership of MDT
11-2J-220
The MDT should provide the names of members of the extended team for named roles
in the team, if they are not already offered as core team members.
The named extended team for the SSMDT should include:
•
•
•
•
•
•
•
•
•
•
SKIN SPECIFIC MEASURES
a core member of the specialist palliative care team;
clinical psychologist/person agreed as able to provide counselling;
a person agreed as able to provide advice on cosmetic camouflage;
clinical geneticist/person agreed as able to provide genetic counselling;
occupational therapist;
person agreed as contact point for prosthetic service;
person agreed as contact point for orthotics service;
physiotherapist;
person agreed as contact point for lymphoedema service;
for a SSMDT sharing its catchment population with that of a MMDT: it should have a
medical oncologist as a member of the extended team if not already offered as a
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core team member.
Compliance:
Name of each extended team member with their role agreed by the lead clinician of the
MDT.
CLINICAL GOVERNANCE OF COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-2J-221
TRAINING FOR MODEL 2 COMMUNITY PRACTITIONERS
This measure has been withdrawn
11-2J-222
This measure has been withdrawn
11-2J-223
PROVIDING PATIENT CENTERED CARE
Patient Permanent Consultation Record
11-2J-224
The MDT should have started to offer patients the opportunity of a permanent record or
summary of at least a consultation between the patient and the doctor when the following
are discussed:
• diagnosis;
• treatment options and plan;
• relevant follow up (discharge) arrangements.
Note:
The MDT may, in addition, offer a permanent record of consultations undertaken at other
stages of the patient's journey.
The record of consultation should identify areas discussed during consultation and
include a diagram where appropriate which supports the consultation discussion.
The consultation record provides a permanent summary of the discussion between the
doctor and the patient and should always be offered to the patient unless specifically
declined by the patient;
A record should be kept in the notes.
Compliance:
The reviewers should enquire of the working practice of the team and see anonymised
examples of records given to patients.
Note:
It is recommended that they are available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
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Patient Experience Exercise
11-2J-225
The MDT should have undertaken or be undertaking an exercise during the previous two
years prior to review or completed self-assessment to obtain feedback on patients'
experience of the services offered.
The exercise should at least ascertain whether patients were offered:
• a key worker;
• assessment of their physical, emotional, practical, psychological and spiritual needs
(holistic needs assessment);
• the MDTs information for patients and carers (written or otherwise);
• the opportunity of a permanent record or summary of a consultation at which their
treatment options were discussed.
Notes:
• The exercise may consist of a survey, questionnaire, focus group or other method.
• There may be additional items in the exercise. It is recommended that other aspects
of patient experience are covered.
The exercise should have been presented and discussed at an MDT meeting and the
team should have implemented at least one action point arising from the exercise.
Compliance:
The results (complete or in progress) of the exercise.
A report for the action taken.
Provision of Written Patient Information
11-2J-226
The MDT should provide written material for patients and carers which includes:
• information specific to that MDT about local provision of the services offering the
treatment for that cancer site;
• information about patient involvement groups and patient self-help groups;
• information about the services offering psychological, social and spiritual/cultural
support, if available;
• information specific to the MDT's cancer site or group of cancers about the disease
and its treatment options (including names and functions/roles of the team treating
them);
• information about services available to support the effects of living with cancer and
dealing with its emotional effects.
It is recommended that the information and its delivery to patients and carers follow the
principles of the NHS Information Prescription project.
(www.informationprescription.info).
Notes:
• The information prescription should be tailored to the patients/carers needs based
on an information needs assessment. Information may be generated and dispensed
outsideof the clinic environments within an information centre where a clear
operational policy between the clinic and information centre is in place which
identifies how clinic records are updated and that facilities and resources within the
information centre are appropriate to providing such a service.
• The information prescription should be composed of information from the national
pathways supplemented with national and local accredited information
Compliance:
The written (visual and audio if used - see note below) material.
Notes:
It is recommended that it is available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
For the purpose of self-assessment the team should confirm the written information which
is routinely offered to patients.
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TREATMENT PLANNING DECISION
Agree and Record Individual Patient Treatment Plans
11-2J-227
The core MDT at their regular meetings should agree and record individual patient's
treatment plans. A record is made of the treatment plan. The record should include:
• the identity of patients discussed;
• the multidisciplinary treatment planning decision (i.e. to which modalities of
treatment, surgery, radiotherapy, chemotherapy, biological therapy, supportive care
or a combination of the same, the case is to be referred for consideration);
• in the case of patients referred to a MMDT, a supranetwork team or another SSMDT
in the network, for the relevant care, the team to which they are referred should be
named.
Note:
A therapeutic operation may in effect form part of the initial investigation and staging
procedure to render the patient suitable for discussion and for subsequent treatment
planning decision. This operation should be recorded.
Compliance:
Anonymised examples of the record of a meeting and anonymised treatment plans.
Notes:
Only exactly what is required in the list above is necessary for evidence. Detailed minutes
of the content of discussions over patients are not required for evidence.
For peer review purposes patient specific information should be anonymised.
It is recommended that this essential information is recorded on an MDT decision
proforma as well as in individual patient's notes.
NETWORK GUIDELINES
Referral Guidelines Between Teams
Introduction
In view of:
i) the various possible configurations for the MDTs;
ii) the need to have agreed the particular configuration for the whole network.
The responsibility for review purposes for referral guidelines between LSMDTs, SSMDTs, MMDTs where
relevant and supranetwork teams lies with the lead clinician of the MDT, the Chair of the NSSG and the
Chair of the Network Board.
For compliance, the Network Board in consultation with the NSSG should produce agreed guidelines and
the individual MDT, for their compliance, should agree to abide by them. The measures count towards the
review of the Network Board and the individual team.
MDT/Network Referral Guidelines Between Named Teams
11-2J-228
The SSMDT should agree referral guidelines compatible with the network board's referral
guidelines between teams (topic 11-1A). The SSMDT's guidelines should include the
following:
• that patients who need level 5 care (as specified in the introduction to the skin
cancer measures) are referred to a named SSMDT;
• that patients who need level 6 care (as specified in the introduction to skin cancer
measures) are referred to the relevant named supranetwork team, or photopheresis
facility;
• for a SSMDT sharing its catchment population with that of a MMDT, level 5 care for
malignant melanoma should be referred to the MMDT.
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Compliance:
The referral guidelines, naming the MDTs and their host hospitals agreed by the lead
clinician of the SSMDT, the Chair of the NSSG and the Chair of the Network Board.
Notes:
The SSMDT may refer patients to a team in another network if compatible with the host
network's guidelines.
Patients for level 6 care may be referred direct to the supranetwork team or via an
SSMDT depending on circumstances.
CLINICAL GUIDELINES
Introduction
Clinical guidelines refer to how a given patient should be clinically managed by which modality(ies) of
treatment (surgery, radiotherapy, chemotherapy, biological therapy) rather than detailed chemotherapy
regimens and techniques of surgery or radiotherapy. More details of regimens or techniques may be agreed
if desired, but they are covered elsewhere in the measures. Because there may not be any comprehensive
national consensus at the level of clinical guidelines, compliance with the measure does not depend on
reviewers' judgement on the details of their contents, although they may comment in their report.
Similar considerations apply to imaging and pathology guidelines (see below). In the case of the IOG for
skin cancer the area of clinical guidelines overlaps to a degree with the descriptions of the particular groups
of patients which are subject to the different levels of care.
The responsibility for review purposes for clinical guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance, the NSSG, in consultation with the MDTs should produce the agreed
network-wide clinical guidelines. The individual MDT for their compliance with this measure, should agree to
abide by them.
MDT Agreement to Clinical Guidelines for the Management of Skin Cancer
11-2J-229
Compliance:
The MDT should agree specified network-wide clinical guidelines with the NSSG. Where
there are agreed national clinical guidelines, the network and the MDT should accept
those.
The network guidelines agreed by the lead clinician of the MDT and the Chair of the
NSSG.
IMAGING GUIDELINES
Introduction
The responsibility for review purposes for imaging guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
imaging group, should produce the network-wide imaging guidelines. The individual MDT for their
compliance with this measure should agree to them.
MDT Agreement to Imaging Guidelines
11-2J-230
Compliance:
The MDT should agree imaging guidelines for the diagnosis and assessment of skin
cancer.
The network imaging guidelines agreed by the lead clinician of the MDT and Chair of the
NSSG.
PATHOLOGY GUIDELINES
Introduction
The responsibility for review purposes for pathology guidelines lies with the lead clinician of the MDT and
the Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
pathology group, should produce the network-wide pathology guidelines. The individual MDT for their
compliance with this measure should agree to them.
MDT Agreement to Pathology Guidelines
11-2J-231
Compliance:
SKIN SPECIFIC MEASURES
The MDT should agree pathology guidelines for the diagnosis and assessment of skin
cancer.
The network pathology guidelines agreed by the lead clinician of the MDT and Chair of
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the NSSG.
Agreed Collection of Minimum Dataset
11-2J-232
The MDT should agree the same minimum dataset (MDS) with other MDTs of the same
cancer site(s) across the network (network-wide MDS). The MDS should include the data
items required for:
• the cancer waiting times monitoring, including Going Further on Cancer Waits in
accordance with DSCN 20/2008, to the specified timetable as specified in the
National Contract for Acute Services;
• the Cancer Registration Dataset as specified in the National Contract for Acute
Services.
The MDS must include all items required for the national contract, any additional items
should use definitions and codes taken from National Cancer Dataset and the NHS Data
Dictionary.
Notes:
• The network MDS may include additional data items.
The MDT should have started to record the MDS or their portion of the MDS for each
patient on proformas and/or in an electronically retrievable form.
Compliance:
The MDS agreed by the lead clinician of the MDT and the Chair of the NSSG.
Note:
For compliance, the NSSG should produce the agreed MDS and the individual MDT for
their compliance with this measure, should agree to collect it.
Anonymised record of data for individual patients.
Note:
For the purpose of self-assessment the team should confirm that they started to record
the MDS in compliance with the details of the measure.
NETWORK AUDIT
Introductory Notes
For review purposes a network audit project is an audit project related to the cancer site or sites of the
NSSG and the activities of its MDTs. The same project should be carried out by all MDTs for that cancer
site in the network, each team's results being separately identified. The individual MDTs, for compliance
with their relevant MDT measure, should agree to participate in the audit. See appendix 1 for audit.
Network Audit
11-2J-233
The MDT should agree to participate in the network audit project agreed by the NSSG.
The MDT should annually review the progress of the project or present the results of the
completed network audit project to the NSSG for discussion at one of their meetings.
Notes:
For MDTs which have previously been peer reviewed the project should have been
completed since that previous peer review.
Compliance:
The audit agreed by the lead clinician of the MDT and the Chair of the NSSG.
Written confirmation of review of progress of audit sufficient to show compliance with the
measure.
Discussion of Clinical Trials
11-2J-234
The MDT should produce a report at least annually on clinical trials, for discussion with
the NSSG. The report should include;
• Details of the MDT's trials portfolio including the extent of local provision of the
national portfolio.
• The MDT's recruitment to the portfolio, including the extent of delivery against the
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locally agreed timescales and targets.
• The MDT's programme for improvement for the above, as proposed to the NSSG.
The MDT should agree a final programme for improvement at the NSSG discussion
meeting.
Note:
For compliance with this measure the MDT should produce a proposed programme for
improvement and, at the discussion with the NSSG, settle on a mutually agreed
programme between the participants of the meeting.
In addition, applicable only to MDTs dealing with the following cancer sites:
•
•
•
•
•
•
Leukaemia
Lymphoma
Germ cell malignancy
Bone and/or soft tissue sarcoma
Brain and CNS malignancy
Malignant melanoma
The MDT should produce a report on clinical trials, covering the above points, for TYA
patients, for discussion with the teenage and young adults' cancer network
co-coordinating group (TYACNCG).
The MDT should agree a final programme for improvement for TYA clinical trials at the
discussion with the TYACNCG.
Note:
The TYACNCG's current list of trials and studies suitable for TYAs may not include any
of those malignancies dealt with by the MDT under review, in which case this is not
applicable for the current assessment in question.
Compliance:
The report, agreed by the lead clinician of the MDT. The reviewers should check that the
contents fulfil the points above.
The programme for improvement, agreed by the lead clinician of the MDT and the clinical
lead for the cancer research network.
Where relevant, the clinical trials report for TYA patients, agreed by the lead clinician of
the MDT, and the programme for improvement agreed by the lead clinician of the MDT,
the Chair of the TYACNCG and the clinical lead for the cancer research network.
MDT WORKLOAD
The issue of viable workload for the SSMDT has been addressed by the measures covering the minimum
catchment population of 750,000 and the requirement for surgical core members to perform a minimum of
15 lymph node block dissections per year.
OPERATIONAL POLICIES REGARDING THE MDT LEAD CLINICIAN AND THE COMMUNITY SKIN
CANCER SERVICE
This measure has been withdrawn
11-2J-235
This measure has been withdrawn
11-2J-236
Joint Treatment Planning for TYAs
11-2J-237
For each patient in the TYA age group, the MDT should agree the following decisions
with the TYA MDT and record them as part of that patient's joint treatment planning
decision:
• the multidisciplinary treatment planning decision (i.e. to which modality(s) of
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treatment-surgery, radiotherapy, chemotherapy, biological therapy or supportive
care, or combinations of the same, they are to be referred to for consideration);
• the named consultant in charge of each modality of definitive treatment and the
named person in charge of organising arrangements for the age-appropriate support
and care environment including those when the treatment is delivered outside the
PTC facility.
For those in the age range 19 to the end of their 24th birthday, the MDT should record
the choice of treatment location, made by the patient, in particular, whether it is the TYA
facility or which of the named designated hospitals for TYAs.
Notes:
Patients in the age range 16 to the end of their 18th birthday should be treated in the
PTC.
The date of joint agreement to the planning and of the patient's choice of treatment place
may be later than the date of the initial treatment planning discussion by the MDT.
Compliance:
The reviewers should ask to see examples of the treatment planning decision record of
patients from the TYA age group. Evidence of joint agreement should be by individual
TYA patient decision records of the site-specific MDT being authorised by a core member
of the TYA MDT.
Note:
If the MDT has had no such patients referred since the last assessment/review this part of
the measure is considered to have been complied with. The overall compliance depends
then, only on the non-TYA aspects of this measure.
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TOPIC 11-2J-3 - MELANOMA MULTIDISCIPLINARY TEAM (MMDT)
When is a Team a Team and When is it not a Team?
The measures review a variety of aspects of the team, both structure and function, but the key question,
which underlies all this, is who exactly constitutes the MDT, from the point of view of the peer review? Which
group of people should be put forward for review against these measures, and who is it who is held compliant
or not compliant? This is best answered from the patient's point of view. If you were a patient, who would you
consider to be your MDT? Primarily it is that group of people of different health care disciplines, which meets
together at a given time (whether physically in one place, or by video or tele-conferencing) to discuss a given
patient and who are each able to contribute independently to the diagnostic and treatment decisions about the
patient. They constitute that patient's MDT.
The way the MDT meeting itself is organised is left to local discretion such that different professional
disciplines may make their contributions at different times, without necessarily being present for the whole
meeting, in order to prevent wastage of staff time. The key requirement is that each discipline is able to
contribute independently to the decisions regarding each relevant patient. For some cancer types the IOG has
laid down detailed requirements over how the diagnostic process should be incorporated into the MDT system
and this has also been translated into the measures where applicable.
Two or more groups of people who may have declared an alliance to form a so-called 'combined' MDT but
who do not all meet together to collectively contribute to the decisions on a given patient as specified above,
do not constitute an MDT from the point of view of peer review. Such alliances have been attempted in order
to achieve, for instance, a minimum caseload or catchment population. This is not appropriate. Each separate
group, meeting as specified above, should be assessed separately against such criteria.
In general the measures should be applied to that defined group, but there are some functions for which
MDTs may combine in a way which is appropriate. Then, the evidence put forward to demonstrate their
compliance with the relevant measures may serve as common evidence across the MDTs but it is applied
separately and compliance is awarded separately to each team.
The main examples of this are as follows:
• a combined operational policy meeting but the policies are agreed on behalf of each MDT by its lead
clinician;
• network-wide clinical, referral, imaging and pathology guidelines, but each MDT agrees to abide by them;
• the same network-wide project for network audit, but each MDT agreeing to participate;
• a common minimum dataset, but each MDT agrees to collect its portion of it;
• a network list of approved trials but each MDT agrees to enter patients;
• an individual health professional being a member of more than one MDT, but a particular defined and
named set of people make up a given MDT.
As well as meeting to make the combined multidisciplinary decisions about patients, the members of some
types of MDTs are required by the measures to carry out another key function in company with other specified
personnel. Thus, some of the more complex surgical procedures should all be performed by the same group
of professionals - surgeon, anaesthetist and skilled theatre and aftercare staff. This is ensured by requiring
services to be organised for that MDT so that all cases of a given procedure are performed in the same
hospital. The people will largely be a different set of people from those who meet to make the diagnostic and
treatment decisions (the MDT as defined in the measures)
but they will directly relate to that MDT and be specified by it, because at least one key functionary, the
surgeon, will be a core member of that MDT.
In requiring all the complex procedures to be performed in the same hospital of the MDT, this ties in the
referral catchment population of the MDT to that hospital. This provides a direct link between the referring
catchment population for MDT discussion, and the treatment caseload of the treatment team and its
hospital facilities.
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The responsibility, for review purposes, for measure 11-2J-301 lies with the lead clinician of the host trust
(see topic 11-1A)
MDT STRUCTURE
Lead Clinician and Core Team Membership
11-2J-301
There should be a single named lead clinician for the MDT who should then be a core
team member.
The lead clinician of the MDT should have agreed the responsibilities of the position with
the lead clinician of the host trust.
Note:
The role of lead clinician of the MDT should not itself imply chronological seniority,
superior experience or superior clinical ability.
The MDT should provide the names of core team members for named roles in the team.
The core team specific to the breast cancer MDT should include:
• two dermatologists;
• two surgeons, at least one of whom should be a consultant surgeon trained in plastic
and reconstructive surgery;
• skin nurse specialist;
• two histopathologists;
• imaging specialist;
• medical oncologist;
• MDT co-ordinator/secretary;
• a NHS-employed member of the core or extended team should be nominated as
having specific responsibility for users' issues and information for patients and
carers;
• a member of the core team nominated as the person responsible for ensuring that
recruitment into clinical trials and other well designed studies integrated into the
function of the MDT.
Notes:
• Each clinical core member should have sessions specified in the job plan for the
care of patients with skin cancer and attendance at MDT meetings.
• For clinical oncologist see measure on extended MDT.
• Where a medical specialty is referred to, the core team member should be a
consultant. The cover for this member need not be a consultant. Where amedical
skill rather than a specialty is referred to, this may be provided by one or more of the
core members or by a career grade non-consultant medical staff member.
• The medically qualified core member(s) depend on the cancer site of the MDT.
• The co-ordinator/secretary role needs different amounts of time depending on team
workload. See the appendix 2 for an illustration of the responsibilities of this role.
The co-ordinator and secretarial role may be filled by two different named individuals
or the same one. It need not occupy the whole of an individual's job description.
• There may be additional core members agreed for the team besides those listed
above.
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Compliance:
Named lead clinician for the MDT agreed by the lead clinician of the host trust.
The written responsibilities agreed by the lead clinician of the MDT and lead clinician of
the host trust.
Note:
See appendix 2 for an illustration of the responsibilities of this role.
Name of each core team member with their role, agreed by the lead clinician of the host
trust.
Notes:
The reviewers should record in their assessment each case where the post(s) needed to
provide the minimum core membership for a given listed role in the measure is unfilled or
non-existent, or existing posts cannot provide the service. This does not refer to mere
holiday or sickness absence, or less than 67% attendance, and it refers only to the core
member roles listed in the measure, not to additional roles that the MDT has decided
locally to include as core members, e.g. from the list in the 'extended MDT' measure. The
reviewers should identify the particular missing roles and identify the particular MDT in the
report.
The responsibility, for review purposes, for the subsequent measures lies with the lead clinician of the MDT.
Level 2 Practitioners for Psychological Support
11-2J-302
At least one clinical core member of the team should have completed the training
necessary to enable them to practice at level 2 for the psychological support of cancer
patients and carers.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the list in the MDT structure measure for core membership.
• The relevant discipline include medical, surgical, nursing and allied health
professionals.
• If the MDT has one or more clinical core members who are trained to level 3 or 4,
the team is deemed to be automatically compliant with this measure.
• The definition of the levels may be found in appendix 1 of the Psychological Support
measures.
Compliance:
The named member.
Written confirmation of completion of training agreed by the lead clinician of the MDT.
Support for Level 2 Practitioners
11-2J-303
Compliance:
The level 2 practitioner(s) should receive a minimum of 1 hours clinical supervision by a
level 3 or level 4 practitioner per month.
Reviewers should enquire to ascertain that this is taking place.
Team Attendance at NSSG Meetings
11-2J-304
Compliance:
The lead clinician of the MDT or representative should attend at least two thirds of the
NSSG meetings.
The attendance record of the NSSG.
MDT Meeting
11-2J-305
The team should hold its meetings at least fortnightly, record core members' attendance
and have a written procedure governing how to deal with referrals which need a
treatment planning decision before the next scheduled meeting.
(Guidance only - e.g. letters, emails or phone calls between certain specified members,
retrospective discussion at the next scheduled meeting).
Compliance:
Attendance records of the meetings.
Written procedure agreed by the lead clinician of the MDT.
SKIN SPECIFIC MEASURES
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MDT Agreed Cover Arrangements for Core Members
11-2J-306
The MDT should agree named cover arrangements for each core member.
Notes:
This refers to the nominating of staff who should in general be expected to provide cover
for the core members e.g. a specialist trainee on a consultant's team or core members of
the same discipline providing cover for each other. It does not refer to the member
having to provide a person to cover for each and every absence. This aspect is dealt
with by the attendance measure below.
Where a medical specialty is referred to the cover for a core member need not be a
consultant, but should be a specialist trainee or non-consultant career grade.
Compliance:
Written arrangements agreed by the lead clinician of the MDT.
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-307
Compliance:
Core members or their arranged cover (see measures 11-2J-301 and 11-2J-306) should
attend at least two thirds of the number of meetings.
Attendance record of the MDT.
The reviewers should identify that particular roles where attendance is below the
requirement of this measure.
Note:
The intention is that core members of the team should be personally committed to it,
reflected in their personal attendance at a substantial proportion of meetings not relying
instead on their cover arrangements. Reviewers should use their judgement on this matter
and should highlight in their report where this commitment is lacking.
OPERATIONAL POLICIES
Annual Meeting to Discuss Operational Policy
11-2J-308
Compliance:
Besides the regular meetings to discuss individual patients, the team should meet at
least annually to discuss, review, agree and record at least some operational policies.
Confirmation of at least one meeting agreed by the lead clinician of the MDT to illustrate
the recording of at least some operational policies evidenced in the annual report.
Specific Procedures Carried Out in Same Named Hospital
11-2J-309
The following procedures together with their acute post operative care, carried out by the
members of the MMDT, should each take place in the same named hospital. e.g. all
block lymph node dissections should be carried out in the same hospital, and all limb
perfusion in same hospital, but the hospital for block lymph node dissections need not be
the hospital for limb perfusions.
•
•
•
•
•
•
Compliance:
block lymph node dissections;
sentinel node biopsy;
metastatectomy/debulking for recurrent melanoma;
isolated limb perfusion;
isolated limb infusion;
reconstruction procedures involving microvascular surgical techniques.
The reviewers should enquire as to the team's working arrangements.
Note:
For the purpose of self-assessment a list of the procedures and which hospital should be
included in the annual report.
There may be different hospitals for different procedures, but all cases of each individual
procedure of the MDT on the list should be carried out in one hospital.
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Individual Surgical Member Inguinal or Axillary Dissections Workload
11-2J-310
Each individual core surgical member of the MMDT who performs inguinal or axillary
lymph node dissections on the MDT's patients should fulfil the following with regards to
those patients:
• the summed total number of groin plus axillary dissections per year should be 15 or
more.
Notes:
• Only dissections performed for skin cancer count towards the total, but they do not
all need to be for malignant melanoma.
• The total of 15 may consist of entirely inguinal or entirely axillary or a combination of
both types of procedure.
• The total should be averaged over the two most recent complete calendar years
prior to the peer review visit or completed self-assessment.
• For a lymph node dissection to count towards the total the surgeon should have
been present and scrubbed at the procedure as evidenced by their being named as
a participating surgeon in the operation notes.
• This measure does not apply to neck node dissections.
Compliance:
The named members, each with their individual totals.
Operational Policy for Named Key Worker
11-2J-311
There should be an operational policy whereby a single named key worker for the
patient's care at a given time is identified by the MDT for each individual patient and the
name of the current key worker and contact number is recorded in the patient's case
notes. The responsibility for ensuring that the key worker is identified should be that of
the nurse MDT member(s).
The above policy should have been implemented for patients who came under the
MDTs' care after publication of these measures and who are under their care at the time
of the peer review visit.
Notes:
• For information: according to the NICE supportive and palliative care guidance, a
key worker is a person who, with the patient's consent and agreement, takes a key
role in co-ordinating the patient's care and promoting continuity e.g. ensuring the
patient knows who to access for information and advice. This is not intended to have
the same connotation as the key worker in social work.
• It may be necessary to agree a single key worker across both a cancer site specific
MDT and the specialist palliative care MDT for certain patients.
Compliance:
The written policy agreed by the lead clinician of the MDT.
Reviewers should spot check some of the relevant patients' case notes.
Core Histopathology Members Taking Part in the National Specialist Dermatopathology EQA
11-2J-312
Compliance:
SKIN SPECIFIC MEASURES
The core histopathology members of the MDT should be taking part in the National
Specialist Dermatopathology EQA.
Documentary evidence to show they are taking part in the EQA.
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MDT NURSE SPECIALIST MEASURES
Introduction
Why are there currently "nursing measures" for MDTs but no similar requirements for other MDT members?
The modern change to MDT working has created and then highly developed the specific role of nurse MDT
member with its related activities which, in full measure, go to make up the role of cancer nurse specialist.
The roles of the medical specialties in the MDT have not been so profoundly influenced or so extensively
developed by their MDT membership itself compared to that of the MDT nurse specialist. The role
definitions and training requirements of nurse MDT members are not very well established "officially"
outside the MDT world in contrast to the well defined medical specialties with their formal national training
requirements (e.g. there were dermatologists and palliative care physicians before there were established
skin MDTs and specialist palliative care teams). Therefore a particularly strong need was perceived for
using the measures to define more clearly the role of the nurse specialist and to set out minimum training
requirements for nursing input into MDTs. This is in order to establish these roles more firmly in the NHS
infrastructure and to avoid the situation where MDTs can comply with measures by having generalist nurses
who "sit in" on MDT meetings and sign attendance forms but play no defining role in the team's actual
dealings with its patients.
Core Nurse Members Completed Specialist Study
11-2J-313
Each core nurse specialist should have successfully completed a programme of study in
their specialist area of nursing practice, which has been accredited for at least 20 credits
at 1st degree level or equivalent.
Note:
It is strongly recommended that if there is more than one core nurse specialist in the
MDT, they should all be compliant with this measure.
Compliance:
Confirmation of successful completion of the course/module.
Agreed Responsibilities for Core Nurse Members
11-2J-314
The MDT should have agreed a list of responsibilities, with each of the core nurse
specialists of the team, which includes the following:
• contributing to the multidisciplinary discussion and patient assessment/care planning
decision of the team at their regular meetings;
• providing expert nursing advice and support to other health professionals in the
nurse's specialist area of practice;
• involvement in clinical audit;
• leading on patient and carer communication issues and co-ordination of the patient
pathway for patients referred to the team - acting as the key worker or responsible
for nominating the key worker for the patient's dealings with the team.
• ensuring that results of patients' holistic needs assessment are taken into account in
the decision making;
• contributing to the management of the service (see note below);
• utilising research in the nurse's specialist area of practice.
Notes:
• "Management" in this context does not mean clerical tasks involving the
documentation on individual patients i.e. this responsibility does not overlap with the
responsibility of the MDT co-ordinator.
• A list of responsibilities containing all the elements in this measure and the previous
measure would encompass all of the four domains of specialist practice required for
the role of cancer nurse specialist.
• Additional responsibilities may be agreed.
Compliance:
SKIN SPECIFIC MEASURES
The list of responsibilities agreed by the lead clinician of the MDT and the core nurse
specialist(s).
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Attendance at National Advanced Communications Skills Training Programme
11-2J-315
At least core members of the team who have direct clinical contact with patients should
have attended the national advanced communications skills training.
Notes:
• This measure applies only to those disciplines which have direct clinical contact and
which are named in the list in the MDT structure measure for core membership.
• Also, it applies only with regard to members which are in place i.e. if a team lacks a
given core member from that list, it should still be counted as compliant with this
measure provided those members which are in place comply.
• The relevant discipline include medical, surgical, nursing and allied health
professionals.
• The reviewers should record which core members of those relevant are
non-compliant.
Compliance:
Written confirmation of the MDT members who have attended the national advanced
communications skills training programme.
Extended Membership of MDT
11-2J-316
The MDT should provide the names of members of the extended team for named roles
in the team if they are not already offered as core team members.
The named extended team for the MMDT should include:
•
•
•
•
•
•
•
•
•
Compliance:
clinical oncologist;
a core member of the specialist palliative care team;
clinical psychologist/person agreed as able to provide counselling;
a person agreed as able to provide advice on cosmetic camouflage;
occupational therapist;
person agreed as contact point for prosthetic service;
person agreed as contact point for orthotics service;
physiotherapist;
person agreed as contact point for lymphoedema service.
Name of each extended team member with their role agreed by the lead clinician of the
MDT.
PROVIDING PATIENT CENTERED CARE
Patient Permanent Consultation Record
11-2J-317
The MDT should have started to offer patients the opportunity of a permanent record or
summary of at least a consultation between the patient and the doctor when the following
are discussed:
• diagnosis;
• treatment options and plan;
• relevant follow up (discharge) arrangements.
Note:
The MDT may, in addition, offer a permanent record of consultations undertaken at other
stages of the patient's journey.
The record of consultation should identify areas discussed during consultation and
include a diagram where appropriate which supports the consultation discussion.
The consultation record provides a permanent summary of the discussion between the
doctor and the patient and should always be offered to the patient unless specifically
declined by the patient.
A record should be kept in the notes.
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Compliance:
The reviewers should enquire of the working practice of the team and see anonymised
examples of records given to patients.
Note:
It is recommended that they are available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
Patient Experience Exercise
11-2J-318
The MDT should have undertaken or be undertaking an exercise during the previous two
years prior to review or completed self-assessment to obtain feedback on patients'
experience of the services offered.
The exercise should at least ascertain whether patients were offered:
• a key worker;
• assessment of their physical, emotional, practical, psychological and spiritual needs
(holistic needs assessment);
• the MDTs information for patients and carers (written or otherwise);
• the opportunity of a permanent record or summary of a consultation at which their
treatment options were discussed.
Notes:
• The exercise may consist of a survey, questionnaire, focus group or other method.
• There may be additional items in the exercise. It is recommended that other aspects
of patient experience are covered.
The exercise should have been presented and discussed at an MDT meeting and the
team should have implemented at least one action point arising from the exercise.
Compliance:
The results (complete or in progress) of the exercise.
A report for the action taken.
Provision of Written Patient Information
11-2J-319
The MDT should provide written material for patients and carers which includes:
• information specific to that MDT about local provision of the services offering the
treatment for that cancer site;
• information about patient involvement groups and patient self-help groups;
• information about the services offering psychological, social and spiritual/cultural
support, if available;
• information specific to the MDT's cancer site or group of cancers about the disease
and its treatment options (including names and functions/roles of the team treating
them);
• information about services available to support the effects of living with cancer and
dealing with its emotional effects.
It is recommended that the information and its delivery to patients and carers follow
the principles of the NHS Information Prescription project.
(www.informationprescription.info).
Notes:
• The information prescription should be tailored to the patients/carers needs based
on an information needs assessment. Information may be generated and dispensed
outside of the clinic environments within an information centre where a clear
operational policy between the clinic and information centre is in place which
identifies how clinic records are updated and that facilities and resources within the
information centre are appropriate to providing such a service.
• The information prescription should be composed of information from the national
pathways supplemented with national and local accredited information.
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Compliance:
The written (visual and audio if used - see note below) material.
Notes:
It is recommended that it is available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
For purposes of self-assessment the team should confirm the written information which is
routinely offered to patients.
TREATMENT PLANNING DECISION
Agree and Record Individual Patient Treatment Plans
11-2J-320
The core MDT at their regular meetings, should agree and record individual patient's
treatment plans. A record is made of the treatment plan. The record should include:
• the identity of patients discussed;
• the multidisciplinary treatment planning decision (i.e. to which modalities of
treatment, surgery, radiotherapy, chemotherapy, biological therapy, supportive care
or a combination of the same, the case is to be referred for consideration).
Note:
A therapeutic operation may in effect form part of the initial investigation and staging
procedure to render the patient suitable for discussion and for subsequent treatment
planning decision. This operation should be recorded.
Compliance:
Anonymised examples of the record of a meeting and individual anonymised treatment
plans.
Notes:
Only exactly what is required in the list above is necessary for evidence. Detailed minutes
of the content of discussions over patients are not required for evidence.
For peer review purposes, patient specific information should be anonymised.
It is recommended that this essential information is recorded on an MDT decision
proforma as well as in individual patient's notes.
NETWORK GUIDELINES
Referral Guidelines Between Teams
Introduction
In view of:
i) the various possible configurations for the MDTs
ii) the need to have agreed the particular configuration for the whole network;
The responsibility for review purposes for referral guidelines between LSMDTs, SSMDTs, MMDTs where
relevant and supranetwork teams lies with the lead clinician of the MDT, the chair of the NSSG and the
Chair of the Network Board.
For compliance, the network board in consultation with the NSSG should produce agreed guidelines and
the individual MDT, for their compliance, should agree to abide by them. The measures count towards the
review of the Network Board and the individual team.
MDT Agreement to Referral Guidelines Between Named Teams
11-2J-321
The MMDT should agree referral guidelines compatible with the network board's referral
guidelines between teams (topic 11-1A). The MMDT's guidelines should include the
following:
• that patients from the MMDTs overall catchment population who need level 5 care
for malignant melanoma are referred to the MMDT;
• that in addition, patients from the MMDT's local (secondary) catchment population
who need level 4 care for malignant melanoma are referred to the MMDT.
Note:
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The above represents the minimum scope of the MMDT's practice, consistent with
compliance. If the network has agreed to a more extensive malignant melanoma practice
for the MMDT, the referral guidelines which reflect this, are automatically compliant.
Compliance:
The referral guidelines agreed by the lead clinician of the MMDT, the Chair of the NSSG
and the Chair of the Network Board.
CLINICAL GUIDELINES
Introduction
Clinical guidelines refer to how a given patient should be clinically managed by which modality(ies) of
treatment (surgery, radiotherapy, chemotherapy, biological therapy) rather than detailed chemotherapy
regimens and techniques of surgery or radiotherapy. More details of regimens or techniques may be agreed
if desired but they are covered elsewhere in the measures. Because there may not be any comprehensive
national consensus at the level of clinical guidelines compliance with the measure does not depend on
reviewers' judgement on the details of their contents, although they may comment in their report.
Similar considerations apply to imaging and pathology guidelines (see below). In the case of the IOG for
skin cancer, the area of clinical guidelines overlaps to a degree with the descriptions of the particular groups
of patients which are subject to the different levels of care.
The responsibility for review purposes for clinical guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance, the NSSG, in consultation with the MDTs should produce the agreed
network-wide clinical guidelines. The individual MDT for their compliance with this measure, should agree to
abide by them.
MDT Agreement to Agreed Clinical Guidelines for the Management of Malignant Melanoma
11-2J-322
Compliance:
The MDT should agree specified network-wide clinical guidelines for malignant
melanoma with the NSSG. Where there are agreed national clinical guidelines, the
network and the MDT should accept those.
The network guidelines agreed by the lead clinician of the MDT and the Chair of the
NSSG.
IMAGING GUIDELINES
Introduction
The responsibility for review purposes for imaging guidelines lies with the lead clinician of the MDT and the
Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
imaging group, should produce the network-wide imaging guidelines. The individual MDT for their
compliance with this measure should agree to them.
MDT Agreement to Agreed Imaging Guidelines
11-2J-323
Compliance:
The MDT should agree imaging guidelines for the diagnosis and assessment of
malignant melanoma.
The network imaging guidelines agreed by the lead clinician of the MDT and Chair of the
NSSG.
PATHOLOGY GUIDELINES
Introduction
The responsibility for review purposes for pathology guidelines lies with the lead clinician of the MDT and
the Chair of the NSSG. For compliance the NSSG, in consultation with the MDTs and the network cancer
pathology group, should produce the network-wide pathology guidelines. The individual MDT for their
compliance with this measure should agree to them.
MDT Agreement to Agreed Pathology Guidelines
11-2J-324
Compliance:
SKIN SPECIFIC MEASURES
The MDT should agree pathology guidelines for the diagnosis and assessment of
malignant melanoma.
The network pathology guidelines agreed by the lead clinician of the MDT and Chair of
the NSSG.
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DATA COLLECTION
Agreed Collection of Minimum Dataset
11-2J-325
The MDT should agree the same minimum dataset (MDS) with other MDTs of the same
cancer site(s) across the network (network-wide MDS). The MDS should include the data
items required for:
• the cancer waiting times monitoring, including Going Further on Cancer Waits in
accordance with DSCN 20/2008, to the specified timetable as specified in the
National Contract for Acute Services;
• the Cancer Registration Dataset as specified in the National Contract for Acute
Services.
The MDS must include all items required for the national contract, any additional items
should use definitions and codes taken from National Cancer Dataset and the NHS Data
Dictionary.
Notes:
• The network MDS may include additional data items.
The MDT should have started to record the MDS or their portion of the MDS for each
patient on proformas and/or in an electronically retrievable form.
Compliance:
The MDS agreed by the lead clinician of the MDT and the Chair of the NSSG.
Note:
For compliance, the NSSG should produce the agreed MDS and the individual MDT for
their compliance with this measure, should agree to collect it.
Anonymised record of data for individual patients.
Note:
For the purpose of self-assessment the team should confirm that they started to record
the MDS in compliance with the details of the measure.
NETWORK AUDIT
Introductory Notes
For review purposes a network audit project is an audit project related to the cancer site or sites of the
NSSG and the activities of its MDTs. The same project should be carried out by all MDTs for that cancer
site in the network, each team's results being separately identified. The individual MDTs, for compliance
with their relevant MDT measure, should agree to participate in the audit. See appendix 1 for audit.
Network Audit
11-2J-326
The MDT should agree to participate in the network audit project agreed by the NSSG.
The MDT should annually review the progress of the project or present the results of the
completed network audit project to the NSSG for discussion at one of their meetings.
Notes:
For MDTs which have previously been peer reviewed the project should have been
completed since that previous peer review.
Compliance:
The audit agreed by the lead clinician of the MDT and the chair of the NSSG.
Written confirmation of review of progress of audit sufficient to show compliance with the
measure.
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Introduction
Because of the single site specialisation of the MMDT there may not be approved trials in malignant
melanoma on the network list, but is expected that whenever there are NCRN approved trials in malignant
melanoma they should be included on the network list.
Discussion of Clinical Trials
11-2J-327
The MDT should produce a report at least annually on clinical trials, for discussion with
the NSSG. The report should include;
• Details of the MDT's trials portfolio including the extent of local provision of the
national portfolio.
• The MDT's recruitment to the portfolio, including the extent of delivery against the
locally agreed timescales and targets.
• The MDT's programme for improvement for the above, as proposed to the NSSG.
The MDT should agree a final programme for improvement at the NSSG discussion
meeting.
Note:
For compliance with this measure the MDT should produce a proposed programme for
improvement and, at the discussion with the NSSG, settle on a mutually agreed
programme between the participants of the meeting.
In addition, applicable only to MDTs dealing with the following cancer sites:
•
•
•
•
•
•
Leukaemia
Lymphoma
Germ cell malignancy
Bone and/or soft tissue sarcoma
Brain and CNS malignancy
Malignant melanoma
The MDT should produce a report on clinical trials, covering the above points, for TYA
patients, for discussion with the teenage and young adults' cancer network
co-coordinating group (TYACNCG).
The MDT should agree a final programme for improvement for TYA clinical trials with the
TYACNCG.
Note:
The TYACNCG's current list of trials and studies suitable for TYAs may not include any
of those malignancies dealt with by the MDT under review, in which case this is not
applicable for the current assessment in question.
Compliance:
The report, agreed by the lead clinician of the MDT. The reviewers should check that the
contents fulfil the points above.
The programme for improvement, agreed by the lead clinician of the MDT and the clinical
lead for the cancer research network.
Where relevant, the clinical trials report for TYA patients, agreed by the lead clinician of
the MDT, and the programme for improvement agreed by the lead clinician of the MDT,
the Chair of the TYACNCG and the clinical lead for the cancer research network.
Joint Treatment Planning for TYAs
11-2J-328
For each patient in the TYA age group, the MDT should agree the following decisions
with the TYA MDT and record them as part of that patient's joint treatment planning
decision:
• the multidisciplinary treatment planning decision (i.e. to which modality(s) of
treatment-surgery, radiotherapy, chemotherapy, biological therapy or supportive
care, or combinations of the same, they are to be referred to for consideration);
• the named consultant in charge of each modality of definitive treatment and the
named person in charge of organising arrangements for the age-appropriate support
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and care environment including those when the treatment is delivered outside the
PTC facility.
For those in the age range 19 to the end of their 24th birthday, the MDT should record
the choice of treatment location, made by the patient, in particular, whether it is the TYA
facility or which of the named designated hospitals for TYAs.
Notes:
Patients in the age range 16 to the end of their 18th birthday should be treated in the
PTC.
The date of joint agreement to the planning and of the patient's choice of treatment place
may be later than the date of the initial treatment planning discussion by the MDT.
Compliance:
The reviewers should ask to see examples of the treatment planning decision record of
patients from the TYA age group. Evidence of joint agreement should be by individual
TYA patient decision records of the site-specific MDT being authorised by a core member
of the TYA MDT.
Note:
If the MDT has had no such patients referred since the last assessment/review this part of
the measure is considered to have been complied with. The overall compliance depends
then, only on the non-TYA aspects of this measure.
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TOPIC 11-2J-4 - THE SUPRANETWORK T-CELL LYMPHOMA
MULTIDISCIPLINARY TEAM FOR TOTAL SURFACE ELECTRON BEAM
THERAPY
Introduction
This section contains measures for the supranetwork T-cell cutaneous lymphoma team. This is a team which
has been selected by specialist commissioners to deal with a particular group of cutaneous T-cell lymphoma
(CTCL) patients for the whole of their host network and also other named networks. The team is built around
the special expertise and facilities required to offer Total Surface Electron Beam Therapy (TSEBT). The
measures concentrate on delivering this therapy. The many other measures relevant to the general functions
of an MDT and the quality of care of these patients, are considered for the purpose of peer review to have
been covered by the review of their referring SSMDTs.
The team may choose to have additional core and/or extended team members besides those specified here.
Possible working models for such a team may involve it being part of an existing SSMDT or
video-conferencing with any referring clinician. These or other models are not precluded provided the team
fulfils the measures in this section.
Whether the supranetwork team undertakes other aspects of management of CTCL besides TSEBT is subject
to arrangements between networks.
At which stage in the patient pathway the patient needs to be seen by a member of the supranetwork team,
and whether a given patient needs to be seen, is again subject to arrangements between networks.
MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
The responsibility for review purposes for measure 11-2J-401, lies with the lead clinician of the host trust.
MDT STRUCTURE
Lead Clinician and Core Team Membership
11-2J-401
There should be a single named lead clinician for the MDT who should then be a core
team member.
The lead clinician of the MDT should have agreed the responsibilities of the position with
the lead clinician of the host trust.
Note:
The role of lead clinician of the MDT should not itself imply chronological seniority,
superior experience or superior clinical ability.
The MDT should provide the names of core team members for named roles in the team.
The MDT should have at least the following core members:
• clinical oncologist who has direct patient care programmed activities, in a
radiotherapy department with a total surface electron beam therapy practice;
• histopathologist who is the named histopathologist for cutaneous lymphoma for a
network (see measure 11-1C-112j);
• dermatologist who is a core member of an SSMDT;
• MDT co-ordinator/secretary;
• a member of the core team nominated as the person responsible for ensuring that
recruitment into clinical trials and other well designed studies are integrated into the
function of the MDT.
Notes:
• Each clinical core member should have sessions specified in the job plan for the
care of patients with skin cancer and attendance at MDT meetings.
• Where a medical specialty is referred to the core team member should be a
consultant. The cover for this member need not be a consultant. The
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
•
•
•
•
Compliance:
co-ordinator/secretary role needs different amounts of time depending on team
workload.
The co-ordinator/secretarial roles may be filled by two different named individuals or
the same one. It need not occupy the whole of an individual's job description.
The team may choose to have additional core and/or extended team members
besides those specified here. Possible working models for such a team may involve
it being part of an existing SSMDT or video-conferencing with any referring clinician.
These or other models are not precluded provided the team fulfils the measures in
this section.
Whether the supranetwork team undertakes other aspects of management of CTCL
besides TSEBT is subject to arrangements between networks.
At which stage in the patient pathway the patient needs to be seen by a member of
the supranetwork team, and whether a given patient needs to be seen, is again
subject to arrangements between networks.
Named lead clinician for the MDT agreed by the lead clinician of the host trust.
The written responsibilities agreed by the lead clinician of the MDT and lead clinician of
the host trust.
Note:
See appendix 2 for an illustration of the responsibilities of this role.
The name of each core team member agreed by the lead clinician of the MDT.
Confirmation of the named radiotherapy department and job plan of the oncologist.
Confirmation that the histopathologist is a network cutaneous lymphoma pathologist.
Note:
The team should record in their reports each case where the post(s) needed to provide
the minimum core membership for a given listed role in the measure, are unfilled or
non-existent or existing posts cannot provide the service. This does not refer to mere
holiday or sickness absence, or less than 67% attendance, and it refers only to the core
member roles listed in the measure, not additional roles that the MDT has decided locally
to include as core members, e.g. from the list in the 'extended MDT' measure. The
reviewers should identify particular missing roles and identify the particular MDT in the
report.
The responsibility, for review purposes, for the subsequent measures lies with the lead clinician of the MDT.
All Consultant Oncologists Responsible for Performing TSEBT Should be Core Members of the
Supranetwork Team
11-2J-402
Compliance:
Any consultant oncologist in the supranetwork catchment area of the MDT who is
responsible for performing TSEBT should be a core member of the supranetwork team.
The reviewers should enquire of the working practice of any consultant delivering this
treatment in the catchment area.
Core member list of the MDT.
Note:
For the purpose of self-assessment confirmation of who is responsible for performing
TSEBT.
This measure, together with 11-2J-401, is intended to ensure that all TSEBT is delivered
by a core clinical oncologist of the supranetwork team, whilst allowing for the situation
where there is more than one such practising oncologist.
All Treatments with TSEBT Should be Delivered in the Same Department
11-2J-403
Compliance:
All treatments with TSEBT for patients from the supranetwork catchment area of the
team should be delivered in the same department.
The reviewers should enquire of the team working arrangements.
Note:
For the purposes of self-assessment confirmation of which department delivers all
treatments with TSEBT in the operational policy.
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
MDT Meeting
11-2J-404
The MDT should meet at an agreed frequency, record core members attendance and
have a written procedure governing how to deal with referrals which need a treatment
planning decision before the next scheduled meeting.
(Guidance only - e.g. letters or phone calls between specified members, retrospective
discussion at the next scheduled meeting).
Compliance:
Attendance records of the meeting.
Written procedure agreed by the lead clinician of the MDT.
MDT Agreed Cover Arrangements for Core Member
11-2J-405
The MDT should agree named cover arrangements for each core member.
Notes:
This refers to the nominating of staff who should in general be expected to provide cover
for the core members e.g. a specialist trainee on a consultant's team or core members of
the same discipline providing cover for each other. It does not refer to the member
having to provide a person to cover for each and every absence. This aspect is dealt
with by the attendance measure below.
Where a medical specialty is referred to the cover for a core member need not be a
consultant but should be a specialist trainee or non-consultant career grade.
Compliance:
Written arrangements agreed by the lead clinician of the MDT.
Core Member (or Cover) Present for 2/3 of Meetings
11-2J-406
Compliance:
Core members or their arranged cover (see measures 11-2J-401 and 11-2J-405) should
attend at least two thirds of the number of meetings.
Attendance records of the MDT.
The reviewers should identify the particular roles where attendance is below the
requirements of this measure.
Note:
The intention is that core members of the team should be personally committed to it,
reflected in their personal attendance at a substantial proportion of meetings, not relying
instead on their cover arrangements. Reviewers should use their judgement on this matter
and should highlight in their report where this commitment is lacking.
TREATMENT PLANNING DECISION
Agree and Record Individual Patient Treatment Plans
11-2J-407
The MDT at their regular meetings should agree and record the patient's diagnosis and
subsequent treatment plans. The records should include:
• the identity of the patients discussed;
• the multidisciplinary treatment planning decision; in particular whether or not;
• TSEBT is to be used;
• they are to be otherwise managed by the supranetwork team or the referring
MDT.
Compliance:
Anonymised examples of the record of a meeting and individual anonymised treatment
plans.
Notes:
Only exactly what is required on the list above is necessary for evidence.
Detailed minutes of the contents of discussions over patients are not required for
evidence.
For review purposes, patient specific information should be anonymised.
It is recommended that this essential information is recorded on an MDT decision
proforma as well as in individual patient's notes.
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
PROVIDING PATIENT CENTRED CARE
Provision of Written Patient Information
11-2J-408
The MDT should provide written material for patients and carers which includes:
• information specific to TSEBT about local provision of the services offering the
treatment for that cancer site;
• information about patient involvement groups and patient self-help groups;
• information about the services offering psychological, social and spiritual/cultural
support, if available;
• information specific to the MDT's cancer site or group of cancers about the disease
and its treatment options (including names and functions/roles of the team treating
them);
• information about services available to support the effects of living with cancer and
dealing with its emotional effects.
It is recommended that the information and its delivery to patients and carers follow the
principles of the NHS Information Prescription project.(www.informationprescription.info).
Notes:
• The information prescription should be tailored to the patients/carers needs based
on an information needs assessment. Information may be generated and dispensed
outside of the clinic environments within an information centre where a clear
operational policy between the clinic and information centre is in place which
identifies how clinic records are updated and that facilities and resources within the
information centre are appropriate to providing such a service.
• The information prescription should be composed of information from the national
Compliance:
The written material.
Notes:
It is recommended that it is available in languages and formats understandable by
patients including local ethnic minorities and people with disabilities. This may necessitate
the provision of visual and audio material.
For purposes of self-assessment the team should confirm the written information which is
routinely offered to patients.
Discussion of Clinical Trials
11-2J-409
The MDT should produce a report at least annually on clinical trials, for discussion with
the NSSG. The report should include;
• Details of the MDT's trials portfolio including the extent of local provision of the
national portfolio.
• The MDT's recruitment to the portfolio, including the extent of delivery against the
locally agreed timescales and targets.
• The MDT's programme for improvement for the above, as proposed to the NSSG.
The MDT should agree a final programme for improvement at the NSSG discussion
meeting.
Note:
For compliance with this measure the MDT should produce a proposed programme for
improvement and, at the discussion with the NSSG, settle on a mutually agreed
programme between the participants of the meeting.
In addition, applicable only to MDTs dealing with the following cancer sites:
•
•
•
•
SKIN SPECIFIC MEASURES
Leukaemia
Lymphoma
Germ cell malignancy
Bone and/or soft tissue sarcoma
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MEASURE DETAILS & DEMONSTRATION OF COMPLIANCE
• Brain and CNS malignancy
• Malignant melanoma
The MDT should produce a report on clinical trials, covering the above points, for TYA
patients, for discussion with the teenage and young adults' cancer network
co-coordinating group (TYACNCG).
The MDT should agree a final programme for improvement for TYA clinical trials with the
TYACNCG.
Note:
The TYACNCG's current list of trials and studies suitable for TYAs may not include any
of those malignancies dealt with by the MDT under review, in which case this is not
applicable for the current assessment in question.
Compliance:
The report, agreed by the lead clinician of the MDT. The reviewers should check that the
contents fulfil the points above.
The programme for improvement, agreed by the lead clinician of the MDT and the clinical
lead for the cancer research network.
Where relevant, the clinical trials report for TYA patients, agreed by the lead clinician of
the MDT, and the programme for improvement agreed by the lead clinician of the MDT,
the Chair of the TYACNCG and the clinical lead for the cancer research network.
Joint Treatment Planning for TYAs
11-2J-410
For each patient in the TYA age group, the MDT should agree the following decisions
with the TYA MDT and record them as part of that patient's joint treatment planning
decision:
• the multidisciplinary treatment planning decision (i.e. to which modality(s) of
treatment-surgery, radiotherapy, chemotherapy, biological therapy or supportive
care, or combinations of the same, they are to be referred to for consideration);
• the named consultant in charge of each modality of definitive treatment and the
named person in charge of organising arrangements for the age-appropriate support
and care environment including those when the treatment is delivered outside the
PTC facility.
For those in the age range 19 to the end of their 24th birthday, the MDT should record
the choice of treatment location, made by the patient, in particular, whether it is the TYA
facility or which of the named designated hospitals for TYAs.
Notes:
Patients in the age range 16 to the end of their 18th birthday should be treated in the
PTC.
The date of joint agreement to the planning and of the patient's choice of treatment place
may be later than the date of the initial treatment planning discussion by the MDT.
Compliance:
The reviewers should ask to see examples of the treatment planning decision record of
patients from the TYA age group. Evidence of joint agreement should be by individual
TYA patient decision records of the site-specific MDT being authorised by a core member
of the TYA MDT.
Note:
If the MDT has had no such patients referred since the last assessment/review this part of
the measure is considered to have been complied with. The overall compliance depends
then, only on the non-TYA aspects of this measure.
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APPENDIX 1
This appendix is to follow
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APPENDIX 2
2.1 Role of Network (Tumour) Site Specific Groups (NSSGs)
Membership
Network tumour site-specific groups should be multidisciplinary; with representation from professionals across
the care pathway; involve users in their planning and review; and have the active engagement of all MDT
leads from the relevant constituent organisations in the network.
Service Planning
NSSGs should ensure that service planning:
•
•
•
•
•
•
is in line with national guidance/standards (including reconfiguration where necessary);
covers the whole care pathway;
promotes high quality care and reduces inequalities in service delivery;
takes account of the views of patients and carers;
takes account of opportunities for service and workforce redesign;
establishes common guidelines, including clear referral guidelines.
NSSGs should:
• recommend priorities for service development to the network board. (In some networks this is via an
advisory clinical group, consisting of membership from chairs of network groups, trust lead clinicians and
the network team);
• ensure decisions become integrated into constituent organisational structures and processes.
Service Improvement/Redesign
• all NSSGs and individual cancer teams should commit to service improvements;
• process mapping and capacity and demand analyses should become part of the norm;
• requests for additional resources from NSSGs should be accompanied by evidence of involvement in
service improvement/redesign;
• NSSGs should develop/approve high quality information for patient, for use across the network.
Service Quality Monitoring and Evaluation
NSSGs should:
• agree on priorities for common data collection (in line with national priorities e.g. for waiting times,
registries and NCASP), but go beyond this where possible;
• review the quality and completeness of data, recommending corrective action where necessary;
• produce audit data and participate in open review;
• ensure services are evaluated by patients and carers;
• monitor progress on meeting national cancer measures and ensure action plans agreed following peer
review are implemented;
• report identified risks/untoward incidents to ensure learning is spread.
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Workforce Development
NSSGs should:
• consider the overall workforce requirements for the NSSG;
• consider the education and training needs of teams and, where appropriate, of individuals;
• liaise with the network board and with the workforce development confederation to ensure that
appropriate workforce numbers and CPD are available;
• promote links between teams through rotation of staff;
• develop common recruitment/retention strategies;
• take account of opportunities for skill mix changes.
Research and Development
• NSSGs should agree a common approach to research and development, working with the network
research team, participating in nationally recognised studies whenever possible.
Annual Work Plan and Report
NSSGs should:
• draw the above together in an annual work plan in the context of a prioritised clinical governance
development plan, for approval by the network board;
• ensure this is fed into commissioning, with agreements specifying standards, service developments and
improvement, data collection, audit, research, education and training;
• provide an annual report of activity to feed health economy clinical governance reporting processes.
2.2 The Responsibilities of MDT members
Responsibilities of the MDT lead clinician
• ensure that objectives of MDT working (as laid out in Manual of Cancer Services) are met:
• to ensure that designated specialists work effectively together in teams such that decisions
regarding all aspects of diagnosis, treatment and care of individual patients and decisions regarding
the team's operational policies are multidisciplinary decisions;
• to ensure that care is given according to recognised guidelines (including guidelines for onward
referrals) with appropriate information being collected to inform clinical decision making and to
support clinical governance/audit;
• to ensure mechanisms are in place to support entry of eligible patients into clinical trials, subject to
patients giving fully informed consent;
overall responsibility for ensuring that MDT meeting and team meet peer review quality measures;
ensure attendance levels of core members are maintained, in line with quality measures;
ensure that target of 100% of cancer patients discussed at the MDT is met;
provide link to NSSG either by attendance at meetings or by nominating another MDT member to attend;
lead on or nominate lead for service improvement;
organise and chair annual meeting examining functioning of team and reviewing operational policies and
collate any activities that are required to ensure optimal functioning of the team (e.g. training for team
members);
• ensure MDT's activities are audited and results documented;
• ensure that the outcomes of the meeting are clearly recorded and clinically validated and that appropriate
data collection is supported;
• ensure target of communicating MDT outcomes to primary care is met.
•
•
•
•
•
•
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Responsibilities of the MDT Co-ordinator
• facilitate and co-ordinate the functions of the multidisciplinary team meetings;
• ensure the appropriate proportions of patients are discussed at MDTs;
• help with the introduction and changes to proformas used to ensure all patients are discussed, treated
appropriately and outcomes are recorded and reviewed. Ensuring patients' diagnoses,
• investigations, and management and treatment plans are completed and added to the patient's notes;
• managing systems that inform GP's of patient's diagnosis, decisions made at outpatient appointment etc;
• working with staff to ensure all patients have a booked first appointment, investigation and procedure and
record details of patients coming via a different route;
• working with key MDT members to identify areas where targets are not achieved, undertake process
mapping to identify bottlenecks;
• undertake demand and capacity studies where appropriate;
• report changes to MDTs on a monthly basis;
• data collection and recording of data;
• to manage the systems according to guidelines, monitoring milestones and submitting the required
reports in the given format and required times;
• keep comprehensive diary of all team meetings;
• record attendance at meetings;
• take minutes at the multidisciplinary meetings, type notes back in the required format and distribute to all
concerned;
• the post holder will be expected to be instrumental in the development of databases to capture patient
information and report this to the clinicians on a weekly basis;
• inform lead cancer manager of waiting times for patients when these exceed appropriate targets;
• ensure lists of patients to be discussed at meetings are prepared and distributes in advance;
• ensure all correspondence, notes, x-rays, results, etc are available for the meetings;
• ensure action plans for patient care are produced with agreed reviews;
• assist in capturing cancer data on all patients and assist in the development of systems to complement
the cancer audit system;
• ensure members or their deputy are advised of meetings and any changes of date, venue, etc.
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ADDENDUM - Amendments to measures April 2012
Measure number
Comment
Introduction to Skin Cancer Measures
This introduction has been revised to take account of the
revised and updated guidance on the management of
skin cancer in the community, contained in the 2010
update to the NICE IOG on skin cancer, and the 2011
DH revised guidance on GPwSI dermatology and skin
surgery services.
11-1C-105j
Revised research measure
11-1C-109j
Revised measure
11-1C-110j
Revised measure
11-1C-114j
Chemotherapy Algorithm generic measure for NSSGs
11-1C-115j
The TYACN Pathway for Initial Management
11-1C-116j
The TYA Pathway for Follow Up on Completion of First
Line Treatment
11-2J-132, 11-2J-235, 11-2J-327,
11-2J-409
Revised research measure
11-2J-135, 11-2J-237, 11-2J-238,
11-2J-410
Joint Treatment Planning for TYAs
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