Patient centred care & Concept of Multidisciplinary team (MDT) Mr A A Ayantunde, MD; FRCS; FWACS, FRCS (Gen & Colorectal Surgery) Consultant Laparoscopic General & Colorectal Surgeon, VTE Clinical Lead, SUH Southend University Hospital (SUH), England, UK

Concept of MDT The concept of MDT originated in the USA more than 50 years ago. It was primarily designed as an educational forum for doctors and medical students to learn from the expert opinions of different healthcare professionals involved in the care of a patient. MDT has evolved into an integrated team approach to healthcare. MDT focuses on the evaluation and the management of complex patients. Individualised and patient-specific management plans.

Benefits of MDT Timely diagnosis and treatment decisions by most appropriately trained specialists with adherence to national targets. Effective communication between all team members. Objective risk assessment and risk prediction to facilitate informed decision making. Shared decision making. Patient optimisation. Key decisions about intended treatment plans.

Multidisciplinary team The multidisciplinary team (MDT) approach has emerged as a way of providing comprehensive medical care by bringing together professionals from a wide range of disciplines in a coordinated and effective manner.

Clinical Governance Clinical governance brought with it accountability. The era of a sole practitioner is fast being eroded and replaced with multidisciplinary setting. The current direction of patient care is towards shared responsibility. There is now a concept of corporate responsibility rather than of the individual clinician’s duty of care.

Dr Harold Shipman (14 January 1946 – 13 January 2004)

Alder Hey organs scandal (1988 to 1995) Involved the unauthorised removal, retention, and disposal of human tissue. During this period organs were retained in more than 2,000 pots containing body parts from around 850 infants. The scandal led to the Human Tissue Act 2004 which created Human Tissue Authority.

Bristol heart scandal (1990s) The Bristol heart scandal occurred in England during the 1990s. At the Bristol Royal Infirmary, babies died at high rates after cardiac surgery. An inquiry found catalogue of inadequacies including lack of coordinated team approach to patient care. The scandal resulted in the publication of the individual cardiac surgeons and hospitals performance data.

Stafford Hospital scandal (Late 2000s) The Stafford Hospital scandal concerned poor care and high mortality rates amongst patients admitted to the Stafford Hospital, England in the late 2000s.  A full-scale investigation was carried out between March and October 2008. The enquiry found ‘appalling conditions and inadequacies’ at the hospital.  The substandard care led to between 400 and 1200 more patients may have died between 2005 and 2008 than would be expected for the type of hospital.

Mr Ian Peterson Scandal (Breast Surgeon)

MDT Setting There is a widespread perception that MDT working has brought benefits to patients and that decision making has improved. A typical MDT meeting needs to bring together staff with the necessary knowledge, skills and experience to ensure high quality diagnosis, treatment and care. MDT is designed in order to improve treatment standards and the overall experience of the patients in general.

Membership of MDT MDT comprises of Core and Extended members.

MDT Membership: Core and extended members

MDT & Patient centred care

Cancer MDT

MDT Recommendations MDT makes management recommendations based on the facts provided. The ultimate responsibility of the implementation still lies on the primary clinician after discussion with the patient and their family. MDT recommendations must be patient centred and in their best interest.

A typical MDT Setting

High Risk Cancer Surgery MDT

MDT Co-ordinator The MDT co-ordinator is a core member and probably one of the most important members of the team. Their role is pivotal to an effective and efficient MDT.

MDT Lead Usually a clinician and preferably a senior member with wide knowledge and expertise in the specialty. The Lead chairs the meeting and it is for him/her to decide (in consultation with others as he/she sees fit) whether there is adequate representation at a single meeting to make safe recommendations. The chair is responsible for raising concerns about non-attendance of particular members.

The Roles of the MDT Lead The MDT chair is responsible for the organisation and the running of the MDT meetings. The chair has skills in the following areas: • Meeting management • Listening & communication • Interpersonal relations • Managing disruptive personalities & conflict • Negotiations • Facilitating effective clinical decision-making • Time-management

MDT Attendance MDT members have dedicated time included in their job plans and attend MDT meetings. Core members are present for the discussion of all cases where their input is needed. Every effort should be made to ensure that a clinician who has met the patient whose case is being discussed is present at the meeting. A register of attendance is maintained. Extended members and non members attend for the cases that are relevant to them.

MDT Members roles Each MDT member has clearly defined roles and responsibilities within the team which they have signed up to and which are included in their job plans. MDT members play a role in sharing learning and best practice with peers.

Patient Centred Clinical Decision-Making Patients are aware of the MDT, its purpose, membership, when it meets and that their case is being/has been discussed and are given the outcome within a locally agreed timeframe. A patient’s views/preferences/holistic needs are presented by someone who has met the patient whenever possible. A named individual at the MDT has responsibility as a key worker for the patient.

Patient Centred Clinical Decision-Making A named individual at the MDT has responsibility for ensuring that the patient’s information needs have been (or will be) assessed and addressed. Patients are given information consistent with their wishes, on their condition, their diagnosis and treatment options including therapies which may be available by referral to other MDTs, sufficient to make a well informed choice/decision.

An effective MDT Improved clinical decision-making More coordinated patient care Improvement to overall quality of care Evidence-based treatment decisions Improved treatment and outcomes Improved overall patient’s experience

The key messages Multidisciplinary team working provides many opportunities to improve the quality of healthcare. Patient is at the core centre of care and their best interest should be the priority and to be respected. Patient-centred outcomes and the concept of shared decision making are key considerations in the MDT approach. The MDT should adopt a holistic approach to the care and treatment of the patient.