My thoughts on some of the problems the NHS has in offering patients with cancer up-to-date care appeared in the Parliamentary Monitor in March. A document came to my attention recently which illustrates some points I made.

I have a colleague who was very enthusiastic indeed about the process of setting up multidisciplinary teams (MDTs) to improve the decision making process for cancer patients. He established the practice of a regular meeting in his specialty almost before the ink was dry on the Calman-Hine report, which was published in 1995. This was designed, following the best principles of Calman-Hine, to accommodate colleagues from surrounding hospitals in planning the care of mutual patients.

In recent years his disillusion has become more evident. He had a commitment which precluded his attendance at a recent meeting and in order to convey his views about the management of one of his patients due to be discussed on that occasion, he wrote the following letter. All that is missed out is the detail that might identify the patient.

"Dear Colleagues,

"Unfortunately, this patient is suffering from the worst aspects of the multi-disciplinary decision making machinery i.e. no decisions, constant discussion, have a go at this, have a go at that. The man is at home. We are no further on. We still do not have an adequate sample of this man's tissue"We have to do better than this and we really need a decision pronto on this man as to whether any treatment of any description is going to be carried out.

"We really need to be much more positive in the handling of this patient. The decision making that goes on in the MDT meeting lacks relevance to the patient. Often it is to do another invasive procedure in the X-ray Department. The department does not have clinical responsibility, it just does its best with the diagnostic process and often that is all it is seeing. We need to have a better and quicker decision making process if we are not to sink under the number of complaints we are likely to generate.

"This patient's wife is coming after the MDT meeting and wants to know what decision and recommendation has been made. My registrar will see her in the first instance and I am hoping to be back early enough to see one of the radiologists to discuss the situation because I am ashamed."

It is beyond doubt that the multidisciplinary process is essential for optimum care of patients with cancer. So why has an enthusiast come to feel ashamed of its working?

I believe the answer lies in the way the service has failed to develop capacity over the years and the way in which its bureaucracy assumes that the capacity is there. It can cope very easily with easily-reached diagnoses; these are readily accommodated in the referral process governed by the two week rule, a process which is being streamlined by the Cancer Collaborative. The system falls down when the diagnosis is not clear and confirmation hard to come by.

When a patient presents these difficulties the doctors must decide which tests to do to secure an answer. If the first test fails, a second must be instituted and the cycle may need to be repeated. There are two sources of delay; firstly the capacity of the diagnostic test, for example a CT scanner, is often too limited. This limitation can be due to lack of equipment or shortage of staff. The patient has to wait for a slot. The second is the wait to discuss the result and to plan the next step.

If it is agreed that the forum for discussion is the MDT meeting, there is a delay until the next event comes round. These delays add up and all the while the cancer is growing and the patient's health deteriorating. The alternative is to circumvent them by good old-fashioned informal discussion but the advent of more timetabled meetings in doctors' schedules, especially MDTs, further reduces the time available for chatting, even about patients' care. Further, discussion outside the MDT defeats its object of involving all relevant disciplines in the discussion. This is compounded by the fact that important disciplines such as clinical and medical oncology may not be represented because of under-provision.

There is also the cultural effect of the formal meeting to which the letter alludes. It is easy to lose sight of the fact that we are working out how best to treat someone's illness in a setting that is more fitted to solving a purely academic problem.

If we ever have a Health Service that is big enough to meet the reasonable needs of the population, it will hold MDTs to guarantee best contemporary management of cancer. It will have sufficient staff and equipment to investigate patients and to solve diagnostic problems rapidly, with people having time both to participate in formal meetings and to engage in efficient informal planning of the patient's care.