Understanding the Multidisciplinary Team Meeting

The Multidisciplinary Team [MDT] meeting, sometimes referred to as the Decision Support Tool [DST] meeting is perhaps the most important part of the entire Continuing Healthcare [CHC] process. This is because, following this meeting, the MDT will be able to make their recommendation regarding eligibility for NHS Continuing Healthcare Funding [CHC].

What is the purpose of the MDT meeting?

At the MDT meeting, the Decision Support Tool will be completed to help identify whether a person’s care needs are the responsibility of the local authority [LA] , often referred to as social services, or whether the needs have gone beyond the LA’s legal responsibility. In this scenario, the NHS will take over the care of the individual for the period of time where needs are beyond those that the local authority can legally manage.

What happens at the MDT meeting?

According to CHC, each one of us has 12 areas of needs [domains]. These are:

• Breathing
• Nutrition – food and drink
• Continence
• Skin and tissue viability
• Mobility
• Communication
• Psychological and emotional needs
• Cognition
• Behaviour
• Drug therapies and medication: symptom control
• Altered states of consciousness
• Other significant care needs

During the MDT meeting these domains will be explored. The CHC practitioner tends to take the lead in the meeting, either reading out or precising their understanding of an individual’s needs and then opening up the discussion to the other parties present to add, correct, clarify and discuss what has been reported.

The CHC practitioner will tend to initially ask questions of the care provider to update and clarify any issues, and then ask those present if they have any questions or information they would like to add.

Once everyone is happy that all needs within that domain have been robustly discussed, the level of need is considered for that particular domain.

This part of the process can be very difficult as the descriptors within the DST can be somewhat confusing and subjective, and frequently a person’s abilities and needs can fluctuate, at times having good days and bad days. This may mean that they fall between several of the levels of need. The aim is to identify the best match, and if in doubt, the higher level of need should be chosen.

It is of note that other professionals or assessment tools may use the same words to describe a level of need. For example, someone may be described as being at HIGH risk of falls. However this does not necessarily translate to a ‘High’ level of need within CHC.

It might be that all those present in the meeting have a different view of the level of need – and that is fine. The purpose of the meeting is to obtain everyone’s views and one of the roles of the CHC practitioner is to document everyone’s opinions.

It is important to note that the levels of need DO NOT determine eligibility for CHC. Only the ‘Primary Healthcare Test’ can do this. It is acknowledged that those receiving good care will naturally score low in certain of the areas considered within CHC. What is being considered throughout is the type of care an individual needs and the degree of intensity, complexity and unpredictability there is associated with the need and the care required to manage it.

Once all 12 domains have been explored and discussed, the meeting will routinely end for the individual and any family/representatives at that point. However, the members of the MDT will continue with the meeting either that same day or a later time that suits all parties. During this second stage, the MDT will apply the Primary Healthcare test, considering the four Key Indicators of Nature, Complexity, Intensity and Unpredictability of the person’s needs to see if those needs have gone beyond the responsibility of the Local authority and, if so, have become the responsibility of the NHS [Continuing Healthcare].

Who will be present at the MDT meeting?

This varies according to the circumstances of the case and where an individual lives. The CHC NHS National Framework sets out best practice and lists those who may be a part of the process. However, the Framework is open to interpretation and all NHS Integrated Care Boards [ICBs] have their own local policies and procedures in place to manage the CHC process.

Those routinely present include:

The individual – who is undergoing an assessment has the right to be present, if appropriate, and according to their choice.

The individual’s family/representative – has a right to be present if the individual so wishes. However, if the induvial does not have capacity to make an informed decision regarding this matter, a Best Interest decision is made as to who should be present at the meeting if the family/representative does not have Lasting Power of Attorney for Health and Welfare.

The CHC practitioner – this will be a health professional. Routinely, it is a nurse who specialises in CHC, but can be from a different health profession.

Local authority representative – this tends to be a social worker. It is of note, that due to local variation, sometimes local authorities do not engage in this part of the process.

Care provider – this can be any member of the care team looking after the individual, whether at home, in a residential care home or a nursing home.

Other professionals can be invited to the MDT meeting if they are part of the individual’s care team (for example, community nurses, physiotherapist, occupational therapist, mental health services). Often they are not able to attend, but information regarding their input will be sought.

Note that the MDT who are involved in the recommendation of eligibility for CHC do not include the individual, their family or advocate. Only the health and social care professionals can make this recommendation.

Our tips: Some Do’s and Don’ts at the MDT meeting:

Do…

1. Be as prepared as possible by looking at the DST document in advance, which can be found on the Department of Health’s website.
2. Have a copy of the DST with you at the meeting.
3. Have a list of points you want to make at the meeting under each domain.
4. Ensure you have allocated sufficient time for the meeting. On average they last for 2 hours, but can easily go on much longer (up to 4 hours on occasion).
5. Remain calm, respectful and approachable in the meeting. These are very difficult meetings, and in order to ensure a robust assessment, it is important to ensure the meeting is not antagonistic.
6. Consider whether you wish to complete a supportive statement which you would like the MDT to look at when they make their recommendation. If so, inform the CHC practitioner of this and ask who, and when, they would like it. Be aware that there is often a rigid time frame within CHC and they will need any information as soon as possible. Therefore, you may wish to send this prior to the MDT meeting; or alternatively, you may prefer to wait to hear what is said at the meeting first before sending it, just in case there are any points you wish to raise from the meeting – but do have the document as prepared as possible in advance, so you simply need to add to it post-meeting.
7. Be aware, that CHC is an evidence-based process and you may well hear the phrase ‘if it’s not written down it didn’t happen’. We all know that this is not the case. However, evidence is vitally important for CHC. So, prior to applying for CHC, inform the care provider that you are looking to pursue CHC and that you will need their help to ensure that all care needs are well-documented. Care providers have a duty to complete written records of the care they are providing and how the individual responds to that care, but many do not do this robustly for many reasons, but without this evidence it can be hard to gain eligibility for CHC.

Don’t…

1. Spend too much time talking about the first few domains as there are 12 to get through and it is important that each domain has enough time allocated to it.
2. Waste time talking about issues that are not relevant to the process. A current CHC assessment is only looking at about three months of evidence. If too much time is spent discussing what happened a year ago, it reduces the time available to discuss the individual’s current needs.
3. Waste valuable time! Be aware that the CHC assessments have to cover certain areas and the CHC practitioner has to ensure these are discussed. There may be areas which are very important to you, but they may not be relevant to CHC, and the CHC practitioner may inform you that this cannot be covered at this time. They are not being dismissive, but simply have to focus on certain issues to ensure a robust assessment is completed.
4. Use the MDT meeting as an opportunity to raise concerns and complaints about the NHS, social care services or the care provider. Any concerns you have are very important and need to be discussed, but the CHC MDT meeting is not the time for this!
5. Interrupt! Allow everyone to express their views without interrupting. When you hear something that you do not agree with, or you have more updated information, it is tempting to jump in. However, this can cause disruption to the meeting. Instead, wait until your time to speak. Make notes whilst others are talking so you can check those points.
6. Argue over points including levels of needs. Instead calmly express your views about care needs including what you have observed and give a clear explanation as to why you feel a certain level of need is appropriate. Above all respect the opinions of others.
7. Forget that when discussing needs in one domain, there will always be potential for overlap into other domains. Although it is important to acknowledge these interactions, be aware that the CHC practitioner may well say ‘ we will capture this later’. That is fine, but simply state that you would like the interaction to be acknowledged in this domain as well.

What happens after the MDT Meeting?

After the meeting, the MDT will normally go away to complete the Primary Healthcare Test and make their recommendation to the ICB.

Some MDTs will contact the individual and/or their representative as soon as they make their recommendation to inform them of this. However, some do not, and you will not hear anything until the decision has been ratified by the ICB which can take several days or more.

Very occasionally, the primary healthcare test may be completed whilst you are present, but don’t expect this.

Ratification of the Recommendation

Different ICBs have different processes in place to ratify the recommendations made by the MDT. Some will have a panel of health and social care managers; other areas will just have one individual reviewing cases.

CHC is evidenced-based and this is often a stumbling point within the process as the evidence may not be robust. When a case goes for ratification, it is important that there is evidence to support the levels of need identified and the overall recommendation. If there is not sufficient evidence and/or the MDT have not given a clear robust rationale for their recommendation, the case may not be ratified until the MDT have reconvened to review their rationales and/or to obtain further evidence to support their conclusions. This can delay the outcome of the process.

Outcome letter

There are two potential outcomes.

The first is that an individual IS eligible for CHC. The date of eligibility will be stipulated on the letter. If you do not agree with this date you can contact the CHC Department [address will be on the outcome letter] and ask for the date of eligibility to be reviewed. The NHS National Framework highlights that date of eligibility will be 28 days after the acceptance of the CHC Checklist. However, this is frequently not the case and different ICBs have their own policies in place for date of eligibility. If you are fortunate, the ICB might backdate eligibility, but be aware this will not be for any significant time. Instead, you might need to request a retrospective assessment.

If found eligible for CHC, be aware that a review will occur within three months, and then as a minimum, ever year thereafter. Should there be any changes in the individual’s care needs this will trigger the full assessment process again, as eligibility is not awarded indefinitely.

The second outcome is that the person is NOT eligible for CHC, in which case, the previously funding arrangements continue. There are rights of appeal which will be documented on the outcome letter.

It is noteworthy that consideration of CHC can take place on several occasions as it is purely based on current needs and needs will frequently alter over time and, if not eligible now, the person may become eligible later.

Here are some helpful blogs for additional reading:

Establishing A Primary Health Care Need

Read about Zara’s experience of her mother’s Multi-Disciplinary Team Assessment…

Never count your chickens… Why MDT assessments are still a cause for concern!

Dissatisfied with your MDT outcome? Consider these potential grounds for appeal…

Part 1: Avoid common mistakes and pitfalls when appealing the MDT decision

Part 2: Avoid common mistakes and pitfalls when appealing the MDT decision

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