MDT feedback – Looe

Multi-Disciplinary Team Meeting Feedback

Old Bridge Surgery Looe – January 2016


Good mix of practitioners including GP’s, Community Matron, District Nurse Manager and Community Nurse Team Leader who does a fixed term dual role within the practice nursing team, Adult Care Social worker and Case Co-ordinator, EIS, Living Well co-ordinator, Project Lead admin support from General Practice. It was acknowledged that the Mental Health team representation has been lacking over the past few months. This was followed up by the GP’s. Community Geriatrician sent apologies but usually helps to chair and facilitate meeting this has been recognised as beneficial especially in deciding risk.

Dates, times and format

This is a monthly meeting which appears to be sustainable for all involved. The meeting has excellent support from the admin team within the surgery sending out dates in advance. Practitioners are expected to feed the people they wish to discuss into this process up until two days prior to the meeting.  These people are all complex with multiple long term conditions and social care needs. The meeting is held in a waiting room upstairs which is usually adequate in space but can be too small when the whole team are present. The surgery are still exploring alternative rooms and how to access IT systems during the meeting, although practitioners do come prepared with peoples notes relevant to the MDT list. The meeting is welcoming with light refreshments.

Format for Living Well communities

The Living Well co-ordinator attends each meeting for the whole duration and uses her expertise to feedback her caseload and accept new referrals. She appears confident to contribute to discussion and is a valued member of the team. This has developed during the past six months and the awareness of existing staff of the Living Well approach and it’s benefits has increased during this time. The MDT is a sharing place for success stories of people who are less socially isolated as a result of this team co-ordinated approach. The culture has changed at this MDT and there is more of a focus on loneliness, loss of independence and social isolation and recognition of the affect this has on people’s health and well-being. The team are managing risk well and working together to provide solutions in complex situations and arranging separate MDT meetings for individuals if required.

Admin support

This is managed really well, very organised with e-mails processed for referrals into MDT so that the agenda is set for the chair. Invites are chased up and non-attendee’s. This co-ordination is paramount to the success of this MDT as the whole team feel supported by this process and the hour taken away from clinical time to discuss the people is productive.


The chair role has been set for consistency and the team have learnt that it is valuable to have a confident member of the team and rotate this every few months. The GP, Community Geriatrician and District Nurse Manager have all contributed to this. The District Nurse Manager is developing well within this role and enjoying the opportunity to use her facilitation skills. The meeting is managed by a traffic light system:

Red – Active Review Status (to be reviewed at next MDT meeting)

Amber – Hold review status (wait and see approach, only discuss if significant change occurs)

Green – Inactive review status (MDT involvement no longer required)

This list is open to all practitioners and used as a format to prioritize discussion during the meeting with Person’s name, Assigned GP and Assigned Key worker. Presentation of person is good with short history, concise and good time keeping.  23 patients were discussed during this hour. The team decide together who is moved up and down the list and on/off. The minutes of the meeting are recorded separate to the list and sent out to the team in a timely manner. The meeting is outcome based ensuring they have captured this before moving onto next person.

It is noted that all GP’s are signed up to attending this MDT which is very much appreciated by community staff and a key ingredient of its success. Hospital admissions are explored at each meeting. There is work in progress with inreach to Community Hospitals with the Community Matron. The community matron is working closely with the whole MDT to do joint visits with all other professionals and will go into the hospital to do a ward round periodically. This is strengthening relationships.

Further points to consider:

  • Interface with community specialist teams for example Respiratory team, invite for selective patients to join beginning or end of meeting? Integrated Care Manger help to make these connections. If GP knows they need to discuss a particular patient with specialist involvement when working up list think ahead
  • Linking this MDT to Community Hospital MDT? Is this possible and how can we do this as a handful of Looe’s patients were in Liskeard Community Hospital
  • Make IT available during the meeting to access GP records to save printing floating papers and for practitioners to access their caseloads
  • Invite to pharmacy and police?
  • Keep chasing mental health services and understand how we can make it easier for them to attend?