Research has repeatedly identified the negative impact that poor coordination and collaboration of health and social care can have on patient outcomes. Both national and international policy makers have advocated an inter-professional collaboration approach to improve quality and patient safety, recognising that patients with complex needs require increased collaboration between health and social care professionals to improve the provision of effective care.

The St Barnabas Multidisciplinary process was co-designed and tested by two multidisciplinary teams, through a series of Plan Do Study Act cycles, based on the principles of the Specialist Level Palliative Care Commissioning Guidance. Logic Modelling was applied to describe intended outcomes and inform evaluation methodology. This rapid quality improvement process was then applied across all services and the co-design group was widened to include other community practitioner stakeholders.

This Specialist Palliative Care Multidisciplinary Team (SpMDT) continues to be refined, yet has a clearly defined purpose and process. Through the co-design process and delivery of SpMDT we have facilitated a culture of learning and improvement and our practice reflects Raine, et al., (2014. Health Services and Delivery Research. 2:37).

Patient outcomes achieved

• Consistent access to high quality SpMDT review and care planning within 7 days of first assessment for all new patients.

• Increased access to SpMDT review and personalised care planning for patients irrespective of diagnosis.

• Access to SpMDT review and care planning for patients with complex needs who are managed by other community practitioners.

Staff outcomes

• Improved confidence in knowledge of skills within the SpMDT.

• Development of specialist palliative care skills and knowledge.

• Improved inter-professional collaboration and learning for the benefit of the health and wellbeing of patients.

System outcomes

• Improved integration between generalist and specialist palliative care service.

• Equitable service delivery.

• Improved communication between wider MDT stakeholders.

• Identification of gaps in resource to inform future and strategic service developments.