Draft 5 – January 2007

5.3 YSBYTY MAELOR

• 
  All patients are reviewed on daily consultant-led ward rounds
  
• 
  A clinical team meeting is held every Monday morning to review all patients to be treated that week with the medical team, day unit nursing team, pharmacist and co-ordinator/tracker
  
• 
  A radiology meeting is held on the first and third Friday of each month to review old and new patients; the medical team, radiologists, CNS, day unit nursing staff attend this meeting
  
• 
  Discussions are held with the histopathologist, oncologist and palliative care team on individual cases as required
  

5.4 JOINT/COMPLEX MEETINGS

• 
  Stem cell meetings are held at Ysbyty Gwynedd on the first Friday of every month to review all stem cell transplant patients. The team from Ysbyty Glan Clwyd attend every other month. The Wrexham team will join this meeting when their stem cell transplantation work is repatriated to North Wales
  

• 
  Where individual complex cases arise, the North Wales Haematology Cancers MDT is available via email, telephone, video-conferencing or the case may be added to the agenda of an existing meeting eg the Blood Club or MDT meeting. Alternatively, members of the MDT may contact nationally recognised experts for advice prior to the local clinical team meeting in order to ensure the delivery of best possible clinical care.
  

6.0 ACCESS TO OTHER SERVICES

6.1 PSYCHOLOGICAL SUPPORT

Psychological support is offered by the clinical nurse specialists/nurse practitioners in the local clinical teams who also provide patients with details of any local support groups. Where specialist support is required patients from Ysbyty Glan Clwyd and Ysbyty Wrexham can be referred to the psychology support team based at Ysbyty Glan Clwyd. Patients at Ysbyty Gwynedd can access specialist courses in stress reduction (Mindfulness). The teams can also access their local psychiatric liaison services if required.

6.2 FERTILITY SERVICES

The MDT supports patients who wish to access fertility services prior to treatment. It is the agreed policy of the MDT that male patients should be referred to St Mary’s in Manchester and female patients should be referred to the specialist gynaecology service at the Liverpool Women’s Hospital. Ysbyty Gwynedd currently provides a sperm storage service but this is under review following the introduction of more stringent legislation in this area and it is likely Bangor patients will soon be referred to St Mary’s in Manchester in line with MDT policy.

6.3 OTHER SUPPORT SERVICES

The MDT has access to dieticians, physiotherapists, OTs and benefits advisors at each site.

6.4 PALLIATIVE CARE

The transition from active treatment to palliative care is handled sensitively in accordance with the patient’s individual needs and wishes. Local clinical teams have access to specialist palliative care where appropriate via the individuals listed in section 3.5 above. Each local clinical team follows its Trust’s agreed end of life pathway.

7.0 PATIENT PATHWAYS

The North Wales Haematological Cancers MDT has agreed to adopt the All Wales patient pathways for haematological cancers where they exist. The lymphoma pathway has been published and is included as Appendix (need to add); work is ongoing to develop All Wales pathways for CLL and AML.

For disease types where there is no All Wales pathway, the MDT will work to develop a local agreed pathway.

8.0 CLINICAL GUIDELINES AND POLICIES

All patients must be treated according to agreed clinical guidelines or as part of a formal clinical trial.

The North Wales Haematological Cancers MDT has agreed the following clinical guidelines:

• 
  The British Committee for Standardisation in Haematology (BCSH) Guidelines– see www.bcshguidelines.com
  
• 
  The North West Region Haematology Guidelines – see www.nwhaems.co.uk
  
• 
  The Myeloma Forum Guidelines – see www.myeloma.org.uk
  
• 
  The CLL Forum Guidelines– see www.cllforum.com
  

(Can these be pulled together and do they include imaging and follow-up?)
All treatment should also be conducted in accordance with the following Network wide policies:

• 
  The North Wales Cancer Network Cytotoxic Chemotherapy Policy 2006
  
• 
  Chemotherapy protocols for each agreed regimen; these will be collated in the next Network Formulary
  
• 
  The North Wales triage guidelines (when agreed)
  

In addition local clinical teams should deliver care in line with local Trust policies on:

• 
  chemotherapy administration (including intrathecal chemotherapy)
  
• 
  infection prevention and control
  
• 
  the use of all medical devices
  
• 
  management of side effects, anaphylactic shock etc
  
• 
  risk management and incident reporting
  

These policies and protocols are available on individual Trust intranet sites.

9.0 RISK MANAGEMENT

All risk management issues and clinical incidents should be addressed by the relevant local clinical team in line with their Trust policy on risk management and incident reporting. Any necessary action should be taken by the local clinical team and the lessons learnt shared with the core MDT.

Any risk management issue involving the whole MDT should be raised with the core MDT by the Trust identifying the issue and dealt with according to their local policy.

10.0 COMMUNICATION

10.1 COMMUNICATION BETWEEN TEAM MEMBERS

There is regular communication between on site team members via daily ward rounds and weekly clinical meetings. Where treatment planning decisions are required between these events, telephone and email communication should be used.

Members of the North Wales Haematological Cancers MDT meet regularly at quarterly MDT meetings, audit and educational meetings. In addition there is regular telephone and email communication between all members of the MDT.

10.2 COMMUNICATION BETWEEN MDT AND PATIENT/CARER

All patients and carers should be given details of how to contact members of the local clinical team when they are given their diagnosis; this may be the contact details of the consultant and/or the clinical nurse specialist.

Patients should be encouraged to bring a family member or friend with them to any consultation where important news is likely to be given. Such consultations should be held in a private room with a nurse present where possible who can then offer further support to the patient. All treatment options should be explained to patients who are then given adequate time to consider their options and make a decision.

10.3 COMMUNICATION SKILLS TRAINING

Communication skills training is available to all members of the MDT involved in direct patient care. All members of the MDT who are likely to give bad news should be encouraged to attend such training.

10.4 PATIENT WRITTEN INFORMATION

Written patient information should be offered to all patients by their consultant, clinical nurse specialist, trials nurse and/or day case senior nurses; senior nurses should also ensure such information is available in ward and outpatient areas.

The North Wales wide patient information folder should be given to all new patients with local information and national leaflets added as appropriate to the individual patient. This information will include leaflets from BACUP, LRF and Macmillan, clinical trials information sheets and local information on MDT arrangements and support groups.

10.5 COMMUNICATION WITH GPs

Following a diagnosis of haematological malignancy, the consultant should write to the patient’s GP informing them of the diagnosis and outline treatment plan.

11.0 DATA COLLECTION AND INFORMATION

The Cancer Network Information System Cymru (CaNISC) does not yet have an agreed minimum data set for haematological malignancies. However all sites within the MDT enter basic demographic and clinical data on haematological malignancies onto CaNISC and will complete the haematological dataset when agreed.

Each hospital submits Patient Episode Database for Wales data based on clinical coding information.

12.0 AUDIT

The MDT participates in all Wales clinical audits as specified by CSCG All Wales Haematological Cancer Steering Group.

In addition, the MDT audit group agrees an annual audit plan of two or three network wide audits per year including audits of practice against agreed clinical guidelines. The MDT is currently undertaking an audit of new DLBCL diagnoses and will then agree its audit plan for the forthcoming year.

13.0 CLINICAL TRIALS

The MDT will review the national list of clinical trials once available and agree which trials it will take part in.

All eligible patients should be given the opportunity to enter an agreed clinical trial. At present this does not occur at Wrexham due to a lack of resources. This issue will be taken forward by the MDT.

14.0 NEW DRUGS

The North Wales Cancer Network is setting up a network wide drugs and therapeutics committee to consider the adoption of new drugs as they appear. The MDT will work with this committee on all new haematological drugs.

15.0 ONGOING EDUCATION

The Blood Club meets three or four times per year for a programme of education. The Blood Club includes Merseyside services.

In addition members of the MDT regularly attend North West Haematologists meetings and the British Society for Haematology, European Society for Haematology and American Society for Haematology annual meetings as well as meetings of the Myeloma Forum, CLL Forum, ALL Forum, BNLI and British Blood Transfusion Service.
Both the core MDT and local clinical teams will review their training needs and agree an educational/training programme as appropriate.

16.0 SERVICE IMPROVEMENT

Service improvement should be discussed at MDT meetings and be embedded within each local service. User involvement should be encouraged in all service improvement initiatives.

17.0 AGREEMENT TO OPERATIONAL POLICY

Signature ………………………………………………….. Date ………………………………………..
Dr David Edwards

Lead Clinician of North Wales Haematological Cancers MDT and Lead Clinician, Haematological Malignancies, Ysbyty Gwynedd

Signature ………………………………………………….. Date ………………………………………..
Dr Christine Hoyle

Lead Clinician, Haematological Malignancies, Ysbyty Glan Clwyd


Signature ………………………………………………….. Date ………………………………………..
Dr David Watson

Lead Clinician, Haematological Malignancies, Ysbyty Maelor

Appendix 1

North Wales Haematological Cancers Core Multi Disciplinary Team
Membership and Terms of Reference
1. Purpose

• 
  The core MDT is responsible for the overall running of the North Wales haematological cancers service. It aims to achieve the best possible outcomes for patients by ensuring access to a uniformly high quality of care across North Wales. It does this by defining and monitoring the operational policy by which all clinicians providing haematological cancer services in North Wales should operate; this operational policy is based on best clinical practice and national guidance.
  

• 
  The core MDT is also the main source of clinical advice to the North Wales Cancer Network Management Board on all matters relating to haematology.
  

2. Membership

• 
  The membership of the core MDT includes representatives from each site providing treatment as part of the North Wales Haematological Cancers MDT:
  
  • 
    Ysbyty Gwynedd, Bangor, part of North West Wales NHS Trust
    
  • 
    Ysbyty Glan Clwyd, Bodelwyddan, part of Conwy and Denbighshire NHS Trust
    
  • 
    Ysbyty Maelor, Wrexham, part of North East Wales NHS Trust
    

• 
  The membership includes representatives of all disciplines involved in the provision of haematology services, in line with Improving Outcomes in Haematological Cancers (NICE, 2003):
  
  • 
    Haematologists
    
  • 
    Pathologists
    
  • 
    Oncologists
    
  • 
    Radiologists
    
  • 
    Clinical Nurse Specialists
    
  • 
    Ward sisters
    
  • 
    Palliative care specialists
    
  • 
    Data co-ordinators
    

• 
  In addition the Network Director, Project Lead and User advisor may be invited as required.
  

• 
  The Chair must ensure there is adequate representation from each site and each staff group at the MDT meeting to ensure their full involvement.
  

3. Chair and Deputy Chair
The Chair and Deputy Chair roles are each for a maximum of five years’ duration. The Chair and Deputy Chair will be nominated by members of the MDT. If there are two or more people nominated, there will be a vote to decide who is elected. The Chair and Deputy Chair will both be agreed by the North Wales Cancer Network Board. The Chair and Deputy Chair will not be from the same Trust.
4. Administrative support
Administrative support will be provided.
5. Frequency of meetings
Meetings will be held at least quarterly.
6. Terms of reference
Service planning

• 
  To act as the Network advisory group for haematological malignancies, advising on service provision and making recommendations for service improvement/development/reconfiguration
  
• 
  To advise the Network on the implications of national policy issues as they arise
  
• 
  To agree an operational policy for the delivery of haematological cancer services across North Wales based on current national guidance and accepted best clinical practice. To review and update this policy annually
  
• 
  To agree referral and clinical guidelines for haematological malignancies. To review and update these guidelines annually and audit their implementation
  
• 
  To agree the optimum patient pathways for each disease type and audit implementation
  

Service improvement and redesign

• 
  To ensure service improvement is embedded within each local team and initiate MDT wide improvements as appropriate
  
• 
  To ensure users are involved in the planning and redesign of services
  

Service quality monitoring

• 
  To ensure clinical services are delivered in accordance with required national standards i.e. JACIE, WAG cancer standards and NICE Improving Outcomes Guidance.
  
• 
  To ensure that the MDT operational policy is implemented effectively on all three sites
  
• 
  To ensure adequate facilities and staff exist on each site to allow full implementation of this policy
  
• 
  To ensure adequate processes are in place on each site to allow full multi-disciplinary involvement in treatment decisions for individual patients. Where necessary to ensure mechanisms are in place for the North Wales MDT to advise on complex individual cases
  
• 
  To agree a minimum data set for haematological malignancies and ensure it is collected on all three sites; to analyse performance and outcome data and take necessary actions
  
• 
  To agree and implement an annual audit programme and review the results of these audits
  
• 
  To ensure services meet national performance targets and quality standards
  
• 
  To address any MDT wide clinical governance concerns raised by local clinical teams
  

Workforce development

• 
  To identify core MDT members’ training needs
  
• 
  To agree an annual educational programme
  

Research and development

• 
  To agree a list of clinical trials, prepare submissions for new trials and ensure all eligible patients are offered the opportunity of entering a clinical trial as appropriate
  
• 
  To work with the Network Drugs and Therapeutics group to agree the implementation of new drugs, preparing all necessary submissions
  

Annual work plan

• 
  To agree an annual work plan for the MDT
  

Appendix 2

North Wales Haematological Cancers Core Multi Disciplinary Team
Lead Clinician Job Description

1. 
   JOB TITLE: Lead Clinician, North Wales Haematological Cancers Core MDT
   

2. 
   ACCOUNTABLE TO: Employing Trust
   

3. 
   OVERALL RESPONSIBILITY:
   

• 
  To be responsible for the development and overall running of the North Wales Haematological Cancers MDT
  

• 
  To ensure that a high quality service is delivered to patients under the care of the MDT
  

• 
  To establish and maintain appropriate links with all three Trusts involved in the MDT and with colleagues in the North Wales Cancer Network, primary care and the All Wales Haematological Cancers Group
  

• 
  To be responsible for providing professional advice within and outside the North Wales Cancer Network on the tumour site and the MDT’s services
  

4. 
   KEY WORKING RELATIONSHIPS:
   

• 
  Members of the core multi-disciplinary team
  
• 
  Cancer and Haematology Clinical Directors of the three Trusts involved in the MDT
  
• 
  Medical Directors of the three Trusts involved in the MDT
  
• 
  Cancer and Haematology Directorate Managers of the three Trusts involved in the MDT
  
• 
  Director, North Wales Cancer Network
  
• 
  Lead Nurse, North Wales Cancer Network
  
• 
  Project Co-ordinator, North Wales Cancer Network
  

5. 
   SPECIFIC DUTIES:
   

1. 
   To set up the North Wales Haematological Cancers Multi-Disciplinary Team in line with NICE guidance and supported by the North Wales Cancer Network
   

2. 
   To agree the membership and role of the core multi-disciplinary team
   

3. 
   To ensure that the core multi-disciplinary team meets at least quarterly with an agreed core membership, records of attendance, and appropriate records of issues discussed.
   

4. 
   To ensure that clinical services are delivered in accordance with required national standards i.e. JACIE, WAG cancer standards and NICE Improving Outcomes Guidance.
   

5. 
   To agree an MDT operational policy for the delivery of haematological cancer services across North Wales based on current national guidance and accepted best clinical practice. To ensure this policy is reviewed and updated annually.
   

6. 
   To ensure that clinical services are delivered in accordance with the MDT operational policy
   

7. 
   To agree with all relevant parties optimum patient pathways, referral guidelines and clinical guidelines for each disease type and ensure these guidelines are reviewed and updated annually.
   

8. 
   To agree an annual audit programme and ensure its outcomes are reviewed.
   

9. 
   To agree a minimum data set for haematological malignancies and ensure mechanisms are in place to collect and review this data
   

10. 
    To agree a list of recognised clinical trials and ensure consistent mechanisms are in place to assess all cancer patients for eligibility into clinical trials.
    

11. 
    To ensure the MDT and local clinical teams review service improvement opportunities and embed them within clinical operational practice wherever possible.
    

12. 
    To identify appropriate training needs of all members of the multi-disciplinary team, and agree at regular intervals how to meet these needs.
    

13. 
    To work with other members of the MDT to ensure patient and carer views of the service are taken into account when planning and delivering services.
    

14. 
    To ensure any MDT wide clinical governance issues raised by local clinical teams are addressed by the core MDT
    

15. 
    To agree an annual work programme for the MDT
    

16. 
    To advise the North Wales Cancer Network Board on issues likely to affect the strategic development of haematological cancer services.
    

6. TENURE:
The post is tenable for a period of up to five years from the date of acceptance.

Signed Signed
…………………………………………………. ……………………………………………

Date: …………………………………………... Date: ……………………………………..

Draft 5 Haematology Operational Policy

January 2007