Prof David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society.
Since leaving my role as national clinical director at the end of last year, I have found myself seconded for day a week to the NHS Emergency Care Support Team and to the Kings Fund alongside my clinical day job. In this new capacity, I have gone into a number of busy acute hospitals or health economies to review care pathways for older people. It has been fascinating to meet so many hard-working colleagues and to see the similarities and differences in how older people’s services are delivered. A key focus in these visits is ensuring that – whatever the issues may be with external delays waiting for “step down” community services or social care – we do, as hospital teams whatever we can internally to minimise delays in our own care pathways.
I realise that I hardly need to preach any of this gospel to fellow geriatricians or other clinicians who read this blog. But for the uninitiated, key principles include; provision of early senior specialist assessment at the front door of the hospital seven days a week; including comprehensive geriatric assessment (CGA) and involvement of specialist nursing, therapies, mental health or social care as indicated; rapid turnaround straight back to community settings where hospitalisation isn’t needed and credible alternatives are in place; commencement of discharge planning on day one; daily focus on discharge planning, expected discharge dates and goals required for patients to be “medically fit for discharge”; with regular senior review, seven day service provision; continuity of care and avoidance of repeated moves; minimising delays in investigation or response to referrals and avoiding complications of hospitalisation such as immobility or delirium.
Part of this message includes the need for regular, short, focussed “board rounds” even on days where there isn’t a full consultant ward round so the team can “touch base”, new problems discussed, progress reviewed and actions allocated. As one blogger commented recently after a day in my own hospital “more like a grand prix pit-stop than the kind of ward rounds I remember from 30 years ago”.
One thing I have observed, consistently, in my site visits is how attached so many of my fellow geriatricians are to the traditional weekly Multidisciplinary Meeting. I understand these feelings. In my own registrar training in the 1990s, I learned a huge amount about the rigour of discharge planning, goal setting, problem solving and inter-professional collaboration from wise consultants who trained me – lessons I try to pass on to my own trainees to this day.
I also know that for many geriatricians, the MDT Meeting is deeply ingrained in their professional identity. “It’s one of the tools of geriatric medicine. Something we do that others don’t. Comprehensive Geriatric Assessment and MDTs” – several have told me.
Of course the evidence is clear that the use of CGA – especially with a ward-based specialist-led MDT delivers for our older patients. It has been defined as a “multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow up”. But neither in this definition , nor in the various interventions including in Ellis et al Meta-Analysis is it inherent that this has to be delivered via the medium of a weekly or twice weekly sit down MDT meeting, however much of a comfort blanket such meetings may be.
I will nail my own colours to the mast and welcome any debate or brickbats that follow. Acute medicine for older people has changed. We have seen an inexorable rise in emergency admissions, reductions in beds and length of stay, increasing acuity and complexity. Whenever I am on my “needs related” on call, we turn round numbers of older people straight from the front door. Consultants are now generally required to do 3 ward rounds a week and by the time I go round on a Friday, 2/3 of the people who were there on Monday have gone. We are also now expected to visit wards on other days to “troubleshoot” see new patients or participate in board rounds. In my view, a lengthy traditional MDT once a week doesn’t suit this new reality and potentially delays decision-making. Such meetings are not always as popular with social work or therapies colleagues as they are with consultants – as the time taken can divert them away from other work. And we are in effect doing virtual continuous MDTs day in day out. I can’t do a ward round without seeking out the OT or Physio or Nurses as I go, or breaking off to speak to the discharge team or palliative care nurses when they visit the ward. We can no longer delay decisions until MDTs happen.
So what should we use MDT meetings for? I would argue that they are best used for difficult best interests meetings, tricky decisions involving future care or end of life, where we do need to devote some time to sensitive discussions, grey decisions and supporting family caregivers. But in general, if we are talking about all of our patients, every day, isn’t it time to let them go?
Back to my site visits, I can tell you that many colleagues disagree and feel that “board rounds” are superficial, inadequate to do CGA properly for their patients and to an extent have disenfranchised them as the senior decision maker in the team. I can also tell you that generally, colleagues from other disciplines and services prefer this new way of working.
The more things change, the more they stay the same…