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1 MDT Development - Working toward an effective multidisciplinary /multiagency team Classification: Official 2 NHS England INFORMATION READER BOXD irectorateMedicalCommissioning OperationsPatients and InformationNursingTrans. & Corp. StrategyFi nancePublications Gateway Reference:02751 Document PurposeDocument NameAuthorPublication DateTarget AudienceAdditional Circulation ListDescriptionCross ReferenceAction RequiredTiming / Deadlines(if applicable)NHS England : Multi-disciplinary team HandbookSuperseded Docs(if applicable)Contact Details for further informationDocument Status0 This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy.

2 Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranetResourcesLeeds LS2 7UE011382 51041 Jason WestwoodCommunity Nursing - Project OfficerNHS EnglandQuarry HouseThis handbook is one of three service components designed to support commissioners, GP practices and community health and social care staff in planning personalised care and in providing services for people who are living with long term conditions. The Document will be uploaded onto the NHS England Website and therefore will be available for all to England /Nursing/LTC 07 January 2014 CCG Clinical Leaders, CCG Accountable Officers, CSU Managing Directors, Medical Directors, Directors of PH, Directors of Nursing, NHS England Regional Directors, NHS England Area Directors, Allied Health Professionals, GPs#VALUE!

3 This handbook is linked to the Case Finding & Risk Stratification (02750) & Personal Care & Support Planning (02752) HandbooksN/AN/A Classification: Official 3 Document Title Service Component Handbook - MDT Development Subtitle - Working toward an effective multidisciplinary /multiagency team Version number: First published: January 2015 Updated: First Publication Prepared by: Susan Swientozielskyj et al Classification: Official NHS England Equality Statement: Equality and diversity are at the heart of NHS England s values. Throughout the development of the policies and processes cited in this document, we have given due regard to the need to: Reduce health inequalities in access and outcomes of healthcare services integrate services where this might reduce health inequalities Eliminate discrimination, harassment and victimisation Advance equality of opportunity and foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it.

4 Classification: Official 4 Contents Contents .. 4 1 Introduction .. 6 Background .. 6 Service Component handbook for Multi-disciplinary teams.. 7 Who is this handbook for? .. 8 MDT and the NHS Five Year Forward View.. 9 FYFV MDT Opportunities .. 9 Person Centred Care .. 11 2 What is a Multi-Disciplinary/Multi Agency team ? .. 12 Definition .. 12 Core Development Elements of MDT Working .. 12 3 Glossary of Terms .. 13 Health Terms .. 13 Social Terms .. 13 Other Terms .. 15 4 Care Coordinator Function .. 16 Roles and Functions of Care Co-ordinator .. 16 5 Self Assessment .. 18 Bradford, Airedale, Wharfedale Integrated Care for Adults Programme; Effective multi-disciplinary teams development tool.

5 18 QIPP national programme (upto 2013) .. 19 DiabetesE .. 19 6 The Continuum .. 20 Continuum 21 MODEL ONE .. 21 MODEL TWO .. 21 MODEL THREE .. 21 MODEL FOUR .. 22 Good Practice Examples .. 22 Model 1 An introduction to the Gloucestershire Urological Cancer multidisciplinary team Service.. 23 Model 2 Midhurst Macmillan Palliative Care Service King s Fund Review.. 23 Model 3 Oxleas Advanced Dementia Engagement Service .. 24 Model 4 NHS at Home: Community Children s Nursing Services (CCNT) 25 7 Common Principles .. 27 Challenging Principles .. 27 Positive Principles .. 28 8 team Development .. 29 9 Commissioning for Integration .. 31 Definitions of Commissioning for Integration.

6 31 Underpinning Principles .. 31 Classification: Official 5 Development of a Shared Purpose .. 31 Agreeing locally defined outcomes .. 31 Relationship Development .. 32 Accountability & Governance .. 32 33 10 References .. Error! Bookmark not defined. 11 Contributors .. 36 Foreword As a patient with an array of long-term conditions including double above knee, arm muscles and finger amputations coupled with severe hearing loss; I have and continue to personally experience and benefit from an array of non-specialist and specialist health and social professions; and whilst these individual professions are distinctly different in the skills, knowledge and expertise that they possess and also the many varying services they provide, they are in my opinion inextricably linked in the common goal of all health and social professions, that being to keep the individual patient mobile, independent, dexterous and out of hospital wherever possible.

7 So as an individual who will continue to need the many skills and expertise of the many caring health and social care professions for the rest of my life, I feel privileged, that I am able to benefit from the mobility and independence afforded to me by the continuing innovative practices across health and social care . Steve McNeice, Co-chair and patient representative This Handbook is intended to give teams on the ground a practical, non judgemental set of tools to be able to assess their own teams against a set of benchmark descriptions of team working. In looking at the different descriptions of team working and examples, teams can come to an informed decision about how their team needs to function and what they might need to do to change to the desired state.

8 There is no fixed solution or right answer to these questions, different solutions will be appropriate to different circumstances and different stages in team development. For the patient, being part of a multi disciplinary team which supports them with the right input at the right time can be the difference between being in control of their condition or not. Communication and information in a well functioning team are at their optimum. What s more, a well functioning team is much more fun to work in! Peter Kohn, Director Office of CCGs Classification: Official 6 1 Introduction Background May 2013 saw the publication of Integrated Care and Support: our shared commitment which launched a shared vision for integrated care and support to become the norm in the next five years underpinned by a national collaborative programme to help organisations find local solutions to deliver this.

9 In addition, a definition and narrative was published by National Voices. The latter has been fundamental in driving a sense of shared purpose and from the perspective of the individual through a series of I statements. Through the national collaborative for integration, a number of local integration pioneers were identified for the purpose of testing new models of commissioning and payment arrangements, developing and delivering new models of integrated care and support, and to accelerate learning and share this with others. This pioneer programme is managed and supported by NHSIQ. Simultaneously with this, and as part of NHS England s work on integrated care, a national steering group for clinical integrated care and support (CICS) was established.

10 The purpose of this group is to provide broader clinical leadership advice and guidance on integrated care, and support the development of an authoritative and collaborative position on the clinical interventions that will best deliver Integrated Care and Support. Classification: Official 7 Over the past several months, the CICS steering group has been working on three service components to support integrated care; risk stratification and case finding, care planning, and multi-disciplinary teams. Service Component handbook for Multi-disciplinary teams. This handbook is one of three service components designed to support commissioners, GP practices and community health and social care staff in planning personalised care and in providing services for people who are living with long term conditions.