How Sheppey Multi-Disciplinary Team is making a difference to patient care

14 August 2019

Dr Rajiv Shah is a GP at Minster Medical Practice. Over the last nine months, he has been instrumental in establishing the Multi-Disciplinary Team (MDT) in Sheppey, which serves a population of around 47,000 residents.

Sheppey MDT is one of three Multi-Disciplinary Teams in the Swale CCG area that brings together health and social care professionals to work as a team to provide coordinated care for patients who are frail or with complex health needs.

Here Dr Shah explains how the new MDT is working and the difference it is making to patient care.

“As a team we meet on a monthly basis to discuss the patients on our list.  With everyone in the same room, it makes it easier to communicate with each other and get direct feedback from all the individuals who are involved in the care of our patients.  By working together in a more joined up way, we can better coordinate and improve the care for many of our patients.

The team includes the GPs,  a community navigator, district nurse and representatives from the social services and mental health teams.  We also have an MDT Coordinator who leads the MDT and helps manage our caseload.

We usually select patients from the practices’ frailty lists who have been identified as needing extra care and support, but can be managed at home rather than sending them into hospital.

We are also seeing more patients who don’t have a medical need but are isolated and require emotional and social support.  For example, the team recently discussed the case of a 64 year old man with limited mobility in need of better housing.  Our Community Navigator was able to help the person fill in a housing application and liaised directly with social services to make sure he received the necessary support.

Since we started working as an MDT last October, we’ve been able to improve the care for our most vulnerable patients in their own homes. Some patients have complicated needs which require two or three agencies to be involved in their care. With this team approach, we now have direct links to each of the professionals involved in a patient’s care and with improved communication between each of us, we can now focus more on what matters most to our patients.”

The local NHS, local government and the voluntary sector have been involved in developing a local care plan to improve care delivered in people’s homes and local communities, rather than in hospital.  Over £2.6m is being invested by NHS Swale Clinical Commissioning Group over the next two years to develop local care services, with the focus on supporting older people who are frail and those with complex health needs.

For more information about the changes happening to Local Care services go to: