Community mental health team
Appendix 12 Consensus development results from round 2: recommendations for which strength
of agreement was
strongly agree
(median
≥ 7) and
variation in extent of agreement was
low
T
he 68 recommendations are grouped into four tables by strength of agreement. Appendix 12 showsthose recommendations where there was strong agreement (median≥ 7) and low variation in the
extent of agreement (the 21 final recommendations). Appendix 13 shows recommendations where there
was strong agreement (median≥ 7) and moderate or high variation in extent of agreement. Appendix 14
shows those where there was uncertainty (median≥ 4 and ≤ 6.5) and Appendix 15 shows those
recommendations where there was disagreement (median< 4). The quotes in the final column of the
tables reflect each of the distinct points made by panellists in order to explain the causes of variation in extent of agreement.
No participant used the‘don’t know’ option in the second round of ratings.
Item Recommendation Mediana
Mean absolute deviation from the median Variation in extent of agreementb Quotes illustrating variability in agreement (when discussed)c
Recommendations relating to the purpose and functions of MDT meetings 1 MDT meeting objectives
should include locally (as well as nationally) determined goals
8 0.63 Low Not discussed
2 The primary objective of MDT meetings should be to agree treatment plans for patients. Other functions are important but they should not take precedence
8 0.88 Low
3 The objectives of MDT meetings should be explicitly agreed, reviewed and documented by each team
8 0.94 Low
4 Explaining the function of the MDT meeting should be a formal part of induction for new staff
9 0.44 Low
5 MDT discussions should result in a documented treatment plan for each patient discussed
9 0.56 Low
6 There should be a formal mechanism for discussing recruitment to trials in MDT meetings (e.g. having clinical trials as an agenda item)
Item Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb Quotes illustrating variability in agreement (when discussed)c
Recommendations relating to MDT meeting processes 7 All chairpersons should be
trained in chairing skills
7 0.81 Low Not discussed
8 All new patients should be discussed in an MDT meeting even if a clear protocol exists
8.5 0.94 Low
9 Teams should agree what information should be presented for patients brought for discussion in an MDT meeting
9 0.56 Low
10 All new team members should be told what information they are expected to present on patients they bring for discussion in an MDT meeting
9 0.38 Low
11 The objectives of the MDT meeting should be reviewed yearly
9 1 Low
12 Once a team has established a set of objectives for the meeting, the MDT should be audited against these goals (e.g. every 2 years)
7.5 0.94 Low Probably in an ideal world it probably should be
Nurse (heart failure)
I’m not sure what we would audit
Doctor (heart failure)
13 All action points should be recorded electronically
9 0.81 Low Not discussed
14 Implementation of MDT decisions should be audited annually
8 1 Low Discussed and rated together with the recommendation: ‘Once a team has established a set of objectives for the meeting, the MDT should be audited against these goals (e.g. every 2 years)’ 15 Where an MDT meeting
decision is changed, the reason for changing this should always
be documented
9 0.19 Low Not discussed
16 There should be a named implementer documented with each decision
9 0.38 Low
Recommendations relating to the content of discussion in MDT meetings 17 Comorbidities should be
routinely discussed at MDT meetings
8 0.94 Low Not discussed
18 Patients’ past medical history should routinely be available at the MDT meeting
Item Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb Quotes illustrating variability in agreement (when discussed)c
Recommendations relating to the role of the patient in MDT meetings 19 The MDT should actively
seek all possible treatment options, and discuss these with the patient after the meeting
9 0.44 Low This question was reworded. It initially read as:‘Patient preferences should not be routinely discussed, but when making a decision, the MDT should actively seek all possible treatment options, and discuss these with the patient after the meeting.’ The panel agreed to reword so it was a single-issue recommendation 20 Patients should be given
verbal feedback about the outcome of the MDT meeting
8.5 0.94 Low Not discussed
21 Where it would be potentially inappropriate to share the content of an MDT discussion with the patient (e.g. where it may lead to unnecessary anxiety or disengagement from services), the decision not to feedback should be formally agreed and noted at the meeting by the team
9 0.63 Low
a Strength of agreement with the statement is indicated by the median: medians between 7 and 9 indicated agreement, medians between 4 and 6.5 indicated uncertainty, and medians between 1 and 3.5 indicated disagreement.
b Variation in extent of agreement among panellists is indicated by the mean absolute deviation from the median: > 1.75 high, 1.11–1.75 moderate, < 1.11 low.
Appendix 13 Consensus development results
from round 2: recommendations for which strength
of agreement was
agree
(median
≥ 7) and variation
in extent of agreement was
moderate or high
Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb
Quotes illustrating variability in agreement (when discussed)c
Recommendations relating to the purpose and functions of MDT meetings 22 MDT meetings
should be a forum for recruiting patients to clinical trials
8 1.19 Moderate Not discussed
Recommendations relating to the structure of MDT meetings 23 All MDTs should have a designated (rather than a rotating) chairperson for MDT meetings
7 1.75 Moderate It’s quite a difficult skill to necessarily chair an MDT well . . . the MDT becomes temporarily dysfunctional for three months whilst someone is thrown into the position of chair who doesn’t really want to be doing it, and doesn’t necessarily have the skills to do it. So I think it’s quite liberating actually for there to be an appointed position
Doctor (cancer)
Having a designated chair and some sort of succession plan
Patient representative (heart failure and cancer)
Perhaps you don’t want to be considered heavily reliant on one . . . so it would be nice to have two or three people that are taken through
Doctor (heart failure)
I don’t think it has to be designated, ours rotates and it works fine. I think we should learn and have those skills
Team manager (mental health)
24 All teams should have a designated person at each MDT meeting to help identify suitable patients for clinical trials
7 1.88 High I would believe that the entire MDT should be doing that. But we would always have . . . trials nurses are always seen in the MDT, and you know, so every patient who was a potential candidate on the basis of their pathology for a clinical trial should be identified as a candidate
Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb
Quotes illustrating variability in agreement (when discussed)c
It’s not necessary to have it a designated person but it would be nice in an ideal world
Doctor (cancer) 2
It’s impractical, the number of people that would potentially be identified for trials across the whole of the mental health service
Doctor (mental health)
25 All MDTs should have a dedicated MDT co-ordinator/ administrator
9 1.31 Moderate I don’t think there are many oncology MDTs that don’t have it
Doctor (cancer)
I think it would be great to have one actually, because certainly we struggle sometimes getting people to the MDT, and struggle to get things moving when everybody’s quite busy. So actually having a dedicated person who co-ordinates and makes sure everything is in the right place would actually be really beneficial. But certainly in my experience that role doesn’t exist in cardiac care
Nurse (heart failure)
I suppose I think clinicians end up doing a lot of work which could easily be done by someone else, and free up their time to do [other things]
Nurse (mental health)
If a service has a manager then you’d expect the manager to be co-ordinating and gathering the team and addressing the members of their team . . . I see that as my role in my service
Team manager (mental health)
Well I don’t know, I’m not sure that we need them . . . because we’re talking about people who we know . . . the person who’s seen them needs to be able to pull all that together succinctly and report back to the team, why do you need someone to co-ordinate that?
Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb
Quotes illustrating variability in agreement (when discussed)c
Recommendations relating to MDT meeting processes 26 MDT chairpersons
should attend at least one other MDT meeting to identify approaches to improve their chairing skills 8 1.56 Moderate 27 A patient list should be available for all team members to view in advance of an MDT meeting 8.5 1.31 Moderate 28 Presentations should be explicitly framed in the light of a specific query or issue to be discussed 8 1.13 Moderate 29 All MDTs should be audited through external peer-review 8.5 1.13 Moderate
Recommendations relating to the content of discussion in MDT meetings 30 There should be
time within MDT meetings to discuss current and emerging research and evidence only in relation to the case discussed
7.5 1.25 Moderate Discussed and rated together with recommendation:‘There should be time within MDT meetings to discuss current and emerging research and evidence which is not specifically related to an individual case’ 31 Relevant psychosocial issues for patients presented to each type of MDT should be identified and agreed by the MDT 7.5 1.44 Moderate 32 The MDT member who presents the case should routinely consider psychosocial factors and ensure that relevant information is available at the meeting
Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb
Quotes illustrating variability in agreement (when discussed)c
33 Teams should be explicit about the research evidence that they are drawing on when making a decision in the MDT meeting
7 1.25 Moderate
Recommendations relating to the role of the patient in MDT meetings 34 Patients should be
given feedback on which professional groups were present when they were discussed at the MDT meeting
7.5 1.69 Moderate It’s good practice to let people know, and again it’s an
opportunity to explain that care is multidisciplinary and what that might mean
Doctor (mental health)
We’re able to tell them if they wish to know, but we wouldn’t routinely necessarily tell them
Doctor (cancer) 1
On the hand-out it will say you were discussed in MDT which will involve pathologist, gynaecologist, clinical oncologist, so there’s that, but each individual, that’s going to be tricky
Doctor (cancer) 2
They should be aware that the radiotherapist wasn’t there on that day, is that what it means, that’s the problem for me
Doctor (cancer) 3
35 Patients should be given feedback every time they are discussed at an MDT meeting
8 1.25 Moderate Not discussed
36 Patients should be given feedback on all treatment options, even those rejected by the MDT
7 2.25 High I think in cancer . . . where there’s sort of three or four options; surgery, radiotherapy, chemotherapy, endocrine therapy . . . there’s such a high profile that the patients are all very aware of the options, they very much want to know, you know, why in my case am I not being recommended chemotherapy. But that was almost as important as the why you are being recommended radiotherapy etc
Doctor (cancer)
I just thought it was impractical. There may be a number of treatment options for, you know, schizophrenia that are impractical because of the person’s
engagement with treatment or ability to use some of those interventions . . . if you were to have to write that down and
Recommendation Mediana Mean absolute deviation from the median Variation in extent of agreementb
Quotes illustrating variability in agreement (when discussed)c
explain that to your patient, I think you would be entering into very very very long conversation creating a lot of conflict, instead of it being the treatment you think is practical and will hopefully work
Doctor (mental health)
37 Patients should be given written feedback about the outcome of the MDT meeting
7 1.63 Moderate If it’s practical to do so for every single person then you can do . . . if you’ve got a co-ordinator and it’s an extra job . . . verbal is the more effective way of doing it
Nurse (heart failure)
Written feedback, that’s pretty much our model
Doctor (cancer) 1
It’s impractical, and I think it’s different in different trusts. But we will see the patient, tell them of the MDT, do a letter at the outpatient
Doctor (cancer) 2
38 Patients should be able to choose the mode of MDT meeting feedback (e.g. written, phone call, in clinic)
7.5 2.19 High In our situation this is not an issue at all, and yet all the other issues would have been pressed with time constraints. That’s not a challenge at all for us
Doctor (cancer)
It’s just whether this is aspirational or pragmatic isn’t it, so of course in an ideal world of course, but there’s 10,000 heart failure patients . . . this is pragmatic real world MDTs rather than aspirational
Doctor (heart failure)
People always have an identified care co-ordinator meeting with them regularly, if there is a decision or not out of an MDT meeting that feedback should be done in the usual way at their meeting
Doctor (mental health)
I disagree because I thought we can’t actually commit to sending everyone written feedback about what’s happened in the meeting, because of time constraints. So as long as we give feedback that they understand, I thought that was okay
Team manager (mental health) a Strength of agreement with the statement is indicated by the median: medians between 7 and 9 indicated agreement,
medians between 4 and 6.5 indicated uncertainty, and medians between 1 and 3.5 indicated disagreement. b Variation in extent of agreement among panellists is indicated by the mean absolute deviation from the median:
>1.75 high, 1.11–1.75 moderate, <1.11 low.