Description of a typical meeting

At the time of the study, each team (community and hospital) had approximately 20 staff; hospital MDTMs were often complemented by people from collaborating services (specifically chaplaincy, bereavement services and/or pain team). The teams meet independently on the same day and time each week, on a day aligned with their joint teaching sessions. Meeting spaces varied depending on the availability of office space. At times, the rooms were too small for the teams, especially if the projector was used for electronic note sharing and taking.

General format followed in both settings

MDTMs were usually attended by all healthcare staff members, except the person covering triage and those part-time staff who prioritised time to directly see patients. The chair and note-taking functions rotated to promote equality and skill development; one person was charged with looking up any missing information (such as date of referral, diagnosis) via a laptop. In addition, they would confirm whether there was any documentation of a patient’s wishes via an electronic system. Use of other computers and phones was avoided to reduce distractions, although urgent calls were always accepted.

The meetings were nominally scheduled to last 90 min. The format followed a standard structure; introductions for any guests, brief discussion of recent deaths across the part of London they covered (allowing the bereavement officer to then leave), more in-depth discussion of individual complex cases, review of new referrals, an update on staff activities that day including joint visits and 1–1 meetings.

Discussion of complex cases was the core of MDTMs. Colleagues were encouraged to nominate cases prior to the meeting to facilitate record retrieval; however, urgent cases were added during the meeting. Each case presentation was led by one professional (often the keyworker), who would narratively describe the patient and their situation (known as the scenario), with those also familiar with the case contributing spontaneously. Discussion included overview of potential issues and areas staff felt required further support. Attendees would ask questions and offer suggestions, with the intention of reaching a consensus on next steps—such as coordinating a joint visit between different services. The amount of time complex case discussions took varied; occasionally the teams used discussion frameworks or timers to encourage concise descriptions, particularly when there were many cases to cover.

A summary of the case description and a list of action points were formally recorded. The use of a number of locally devised codes for record keeping—‘nature of complexity’, ‘safeguarding or other risks’, ‘rapidly changing condition’, ‘equipment’ and ‘social support’—enabled more time for collective discussion and reflection. In addition, Outcome Assessment and Complexity Collaborative measures were agreed and recorded to describe the stage of illness.9

Key observations

The physical environment affected how meetings unfolded; being cramped into a space and not able to see everyone hampered discussion. A sense of collegiality was established by informal introductions, humour at the start or end of the meeting and simple actions such as sharing fruit and biscuits. While not all case discussions were immediately relevant to all staff present, contributions from anyone were always valued. Different disciplinary perspectives helped question assumptions and provide complementary expertise. New members of the team rapidly learnt how to present, and relate to, complex cases by attending and participating in MDTMs.

While all team members saw MDTMs as a central part of their work, it tended to be framed as a management and administrative task rather than a direct form of patient care. At times, staff expressed concerns that attending meetings reduced time available for interacting with patients and their families, an aspect of their work that they highly valued and was often pressurised due to workload volumes. But in addition to supporting clinical and practical concerns, such as treatment decisions, agreeing joint-visits or tracking patients as they moved been acute and community settings, we observed that MDTMs served several other functions. Staff were able to express their own emotional response to cases that were often complicated and frustrating to deal with. Although these affectual dimensions could not always be resolved, sharing them with the team shifted responsibility and burden from individual professionals to being acknowledged and taken on by the team. Our findings indicate that there can be a difference between what staff perceive the use of meeting to be, which may be more administrative, and the value of the meetings when considering how they influence patient care, staff well-being and collaborative working.

Standardised codes and team discussions established a shared understanding of what a complex case was. Often this related to instances when it is not clear what should happen next or who should take the lead for subsequent actions. Even when no new clinical decision arose, the opportunity to explore different possible ways to proceed had real value, cultivating individual and collective capacity to respond. Since many complex cases were discussed repeatedly at various MDTMs, a longitudinal perspective emerged that helped inform suggestions for how to proceed.