The main findings from the quantitative analysis formed the basis for the following five deductive themes, which we explored further using our qualitative data:
1. theme 1: influence of disease specialty on implementation 2. theme 2: influence of multidisciplinarity on implementation 3. theme 3: influence of team climate on implementation
4. theme 4: influence of socioeconomic characteristics on implementation
5. theme 5: roles that patient preference, health behaviours and other clinical factors may have in explaining the socioeconomic variations in implementation.
Theme 1: influence of disease specialty on implementation
Our quantitative analysis demonstrated significant differences in implementation rates across specialties. However, we also found considerable variation within specialties (e.g. memory clinic 1 implemented 76% of the decisions made, while memory clinic 2 implemented 94%). The qualitative data indicated that this may be because the two memory clinics tended to carry out different functions:
I think the main function . . . it’s discussion about clinical cases and making decisions about clinical cases. Be that assessment, intervention, you know, that would be the main role, and I think there are other roles, like information giving, teaching, sharing, support role, for other practitioners. I think, but
mainly it’s clinical discussion, you know, around cases, and planning around what you’re going to do
with the case.
It [the main aim of the meeting] tends to be making a diagnosis for the client. It is like a diagnostic clinic.
Memory clinic 2 psychologist, interview
High-implementing teams, regardless of disease specialty, more frequently referred to diagnostic or treatment protocols and national guidelines. In the cancer MDTs, for example, all new patients were discussed, many of whom were treated according to standard protocols. This contributed to a higher throughput of patients and higher implementation rates than for those non-cancer teams which focused on discussing only complex cases where the appropriate treatment plan was less clear:
We have protocols for melanoma here, so that’s easy. The same with squamous cell and basal cell
carcinoma there are national guidelines about optimal treatment. And so often the decision is obvious.
Cancer doctor, interview
High-implementing teams also had clear goals, and members shared the view that the main purpose of the MDT meeting was to make treatment recommendations for patients. In contrast, in
lower-implementing teams, members identified a range of diverse objectives and some stated that there was a lack of clarity of purpose:
I am never quite sure what the purpose of the meetings are . . . It was the thing that was done and therefore I did not have any say on whether it was done or not done.
Mental health nurse, interview
All four cancer teams adhered closely to national guidelines, so they had the dedicated administrative support members considered to be essential for meeting preparation and facilitation:
[The MDT co-ordinator] she’s brilliant. She really is. She holds the meeting together very well I think
. . . She’s really, really important. Like she’s not medical in the slightest, but she knows where the
patients are, when they should be treated.
Cancer nurse, interview
High-implementing teams also tended to have permanent and authoritative chairpersons who maintained a focus on decisions, which were clearly recorded.
I think it is the best-run meeting I have attended . . . the person who runs it, he runs it very well in the sense that he is very strict in starting the meeting on time, going through cases promptly.
Cancer diagnostic doctor, interview
In teams with rotating chairpersons, there was some concern that meetings were often left without a confident leader to direct and manage discussions. Occasionally time was spent at the start of the meeting trying to establish whose turn it was to chair that week:
I think one of the weaknesses is everyone chairing and therefore everyone being lumbered two or three times a year . . . seniors chairing the meeting, that makes a little bit more sense, because then that person can deliver their control of the group a bit more . . . [it] was the idea of having everyone as equals but not everyone was as equals.
Mental health nurse, interview
High-implementing teams also assembled lists of patients for discussion in advance of the meeting. This stimulated case presenters to consider the management options they wished to discuss before, rather than
during, the meeting and led to more explicit decisions. The other MDTs included either none or some of these features, and this varied by team rather than by disease type.
Theme 2: influence of multidisciplinarity on implementation
Contrary to policy-makers’ expectations that multidisciplinarity increases the quality of decisions and thus
the likelihood of implementation, the quantitative analysis found that there were increased odds of implementation when there were fewer professional groups in attendance. However, this trend was not consistent across teams and was mostly accounted for by mental health and memory teams. In these teams, when meetings were attended by more professional groups there was a tendency for very diverse issues to be raised in an ad hoc manner, with abrupt changes of subject. For example, the discussion might move from medication to housing problems to employment issues, without a clear summary of what was decided in relation to each issue. There was a lack of focus on specific questions and documentation was inconsistent. Thus, if a key worker was unclear about which of the suggestions had been ultimately agreed, there was rarely a comprehensive record of the discussion to refer to.
In addition, some MDT members found decision-making more difficult when a range of professionals were attending and teams struggled to bring the diverse viewpoints into alignment to agree a plan:
Sometimes I used to think too many cooks . . . you could have too many opinions.
Mental health social worker, interview
Sometimes it feels a bit like they feel like they’re in two camps [social work and nursing] . . . social
workers very much do try to defend, you know a person’s right to be mad. I mean the nurse view is
‘you’re not well so we need to get you on the path and let’s make the decisions you would make’ . . . well social workers, they come from a different point of view.
Mental health nurse, interview
Across all teams, participants emphasised the value of disciplinary diversity and considered multidisciplinary participation a key benefit of MDT meetings:
All of those people bring different things into that mix.
Cancer doctor, interview
In practice, however, there was considerable variation in the degree of multidisciplinary input into
discussions. Some complained that meetings were overly dominated by the medical profession in terms of both the numbers of each discipline represented and the power dynamics involved:
It’s rarely a multidisciplinary meeting. It is in many ways, it often consists of a surgeon talking to the radiologist.
Cancer doctor, interview
It is quite medically dominant. There can be one psychologist and assistant and then a lot of doctors, it can be a very strong medical dominance in terms of what is more likely to be the outcome.
Memory clinic psychologist, interview
Even where disciplines were represented in the team, some felt it was difficult for them to be effective if they were largely outnumbered:
Doing it on your own is very hard. I think MDTs don’t work where you’ve got overwhelming numbers
of one set of professional and just one of another.
Several non-medical MDT members commented that they did not feel a sense of ownership at the meeting and did not always feel able to contribute freely about patient management or the design of the meeting:
The room is full, there are other people in there . . . however they don’t have a voice. I notice that
nobody else speaks. It’s just the consultants that are around the table that discuss among themselves
. . . nobody else has any involvement.
Heart failure nurse, interview
In some teams there was a physical divide with consultants sitting at the front and nurses at the back: The discussion is very much focussed on the people who are sitting at the front and information is
invited from other people if it’s required . . . sometimes does make it difficult to hear and/or be
involved in a discussion.
Cancer nurse, interview
However, some of the doctors found it frustrating that the other professionals did not involve themselves more:
I’m always amazed how very able staff can be so passive . . . it would be nice if the non-medical
people were a little bit more volunteering, didn’t have to draw out, but I’ve given up trying to
expect that.
Heart failure doctor, interview
The principle of multidisciplinary input, therefore, was highly valued by professionals across all disease specialties. However, there was dissatisfaction about the way that it played out in practice.
Theme 3: influence of team climate on implementation
The team meeting was considered important for many aspects of team functioning. Health professionals emphasised that team meetings served a range of social functions in addition to decision-making, including opportunities for peer support, team-building and bonding:
I probably go there because it’s valuable for education, for team building, for giving a sense of
responsibility, for influencing other people’s approach to things, for building up team culture, that’s
the reasons I go.
Heart failure doctor, interview
The MDT meeting was also perceived to be important for understanding the roles of other team members: An opportunity for I think all the staff to be aware of the sort of work that other members of the
team do and I think that’s you know, sort of all helps with sort of cohesiveness of the team and also
you know awareness.
Memory clinic doctor, interview
In this way, MDT meetings were a forum where team climate was cultivated, providing an opportunity to
develop the team’s culture, share learning and develop clear understandings of one another’s roles.
These positive aspects of the meeting were considered key to the general effectiveness of the team. Theme 4: influence of socioeconomic characteristics on implementation
The odds of implementation was lower for more socioeconomically disadvantaged patients. Socioeconomic information was only occasionally mentioned in cancer and heart failure teams. In contrast, it was routinely
discussed in memory clinic and mental health teams:‘he lives with his wife no financial concerns at all’
Has been claiming on and off for seventeen years of his life . . . he’s trapped really I think with his kind
of ideology and the reality that’s he’s on housing benefit. He’s on DLA [disability living allowance] and
he’s on, he couldn’t remember if it’s income support or incapacity erm, and he’s on these benefits so
and he’s taking up our time and resources as a team . . . he’s very bright so he’s in no denial about
that, the reality of that he’s receiving them. And he can’t seem to manage without them. You know,
he can’t hold down a job.
Mental health social worker, observation
Although socioeconomic circumstances were discussed within the context of services provided by mental health and memory clinic teams, it was unclear how, if at all, these influenced decision-making
or implementation.
Theme 5: roles that patient preference, health behaviours and other clinical factors may have in explaining the socioeconomic variations in implementation We explored the roles that patient preference, health behaviours and other clinical factors may have in explaining the socioeconomic variations in implementation that we found in the quantitative analyses. However, although there was marked team variation in discussion of these factors, most members
considered that the extent to which‘health behaviours and other clinical factors’ were discussed
was appropriate:
I think we discuss it when it’s important . . . yes we do bring in physical problems as well which we
need to if necessary.
Memory clinic allied health professional, interview
However, it was acknowledged that information on comorbidities was not always available when making decisions in the MDT meeting:
There may be some instances where we don’t know enough about the comorbidities to make the
decision and have come back to clinic and found that actually the patient’s not fit for a
particular treatment.
Cancer doctor, interview
There were mixed views from patients, with many indicating that they were happy for clinicians to use their judgement when presenting their cases, and that there was nothing specific about them that they would want mentioned. Others felt strongly that their comorbidities were crucial to their quality of life and therefore should be discussed:
What is the point in mending a man’s heart, well not mending it but keeping it going on a really nice
basis, and lungs, if every day he has got wind up to his ear holes, he can’t eat and he feels awful.
It just seems bad, it seems wrong.
Heart failure patient, interview
With regard to patient preferences, some clinicians argued that these should be central to MDT decision-making:
If you don’t take patients’ views into account that does create a lot of problems for the team in the
long run, so I think it’s important for both the patient and the team, so that’s become a big part of
your decision-making.
Others preferred to elicit patient preferences after the MDT, when treatment options could be shared with patients. This was attributed partly to the fact that patient preferences can change over time, but also to the importance of being fully informed before discussing treatment options with a patient in clinic:
One of the values of the MDT meeting is to allow the clinician to actually go into a consultation [after the meeting] with a patient and tell them what the options are, tell them how the decision has been
reached and what the advantages and disadvantages are, and I think that that’s more useful to a
patient than actually giving patients a list of options beforehand . . . and then having the MDT meeting decide that half those options are off the table anyway.
Cancer doctor, interview
In summary, although patients from more deprived areas are less likely to have their treatment plans implemented, consideration of patient preference, comorbidities or other health-related factors did not seem to explain this.
Additional information in regards to discussion of comorbidities is presented in Content of discussion in multidisciplinary team meetings, theme 11. Further discussion of patient preferences in MDT discussions is explored in Content of discussion in multidisciplinary team meetings, theme 13.