Community Integrated Teams (CITs) are now in place to provide an effective, high quality and coordinated response to the most vulnerable people with the most complex needs, keeping them out of hospital.

Based in key localities in the city – Bunny Hill Primary Care Centre; Riverview Health Centre; Houghton Health Centre; Grindon Lane Primary Care Centre and Washington Primary Care Centre – the teams are made up of district nurses, community matrons; general practitioners, practice nurses, social care professionals, living well link workers and carers support workers. By working from one shared base, they are able to avoid duplication of work, which can not only be costly to the NHS, but can also be very frustrating for the patient, who would have to tell their story to each health and care professional providing them with support. The Community Integrated Teams are supported by a MDT Co-ordinator.

The CITs are together creating holistic health care plans with patients and carers, that are absolutely tailored to the needs of the person, and these are supported by their own GP, who will lead clinical decision-making to ensure that the medical, social and emotional needs of their patient are taken into.

MDT’s have now been running in some localities for 4 months now and I don’t know where the time has gone! Most practices are holding weekly MDT meetings which are attended by various professionals who contribute to the MDT Process.

Sunderland GP Alliance have been collecting data round the plans that have been put in place. As at 15.03.2016 there are 743 Person Centred Health and Social Care Plans in place and 428 EHCP’s. The number of patients that have been through the MDT Process are 1324 which is 0.47% of the Total Population with an EHCP or Person Centred Health and Social Care Plan.

A consultation exercise has taken place with General Practice around the MDT Process, we received feedback from more than half the Practices in Sunderland.

Three questions were asked:-

  1. What do you feel is going well with regard to the MDT process and CIT’s?
  2. What do you feel is not going so well?
  3. What suggestions/improvements could be made?

Some of the responses received were:-

What is Working Well?

  • Joint working between Practice, Nursing Teams and Social Care Team as well as the role of the MDT Co-ordinator taking most of the workload!
  • Patients are receiving better care quicker.
  • Embracing being co-located
  • Having weekly MDT’s has worked for our practice
  • We have had very positive outcomes from MDT Meetings but what we have found as a Practice exceptional is the community teams and external agencies commitments to making these MDT meetings work.

What is not working so well?

  • Lack of Data Sharing
  • To get the EHCP plans all up to date and keeping the system going
  • Cancellations at Short Notice
  • “hot desking” does not always work – some work needs to be done here to ensure all feel an equal member of C.I.T’s
  • Confusion over the practices and everyone doing different things within the City.

Suggested Improvements

  • Sharing Good Practice
  • Create Clear Guidelines
  • A standard format for the process that is reviewed regularly to ensure compliance.
  • Clarification around the Risk Stratification
  • Frequency of Meetings – do they need to be weekly?

Now that the Community Integrated Teams work programme is now fully mobilised, it is now time to stop and reflect on our work to date and how we proceed into 2016/2017. The Care Planning Group has been established and will look at:-

  1. The MDT Process – To standardise the MDT process and put together some minimum standards for MDT’s.
  2. Risk Stratification – Are we using the correct tool? Are we targeting the right patients?
  3. Care co-ordinator role – to provide further guidance.

The Care Planning Group is currently in the process of producing a guidance document around MDT’s and this will be shared with partner’s agencies as soon as completed.

“The Alliance has been confirmed as the integrator of GP input into Integrated Teams for 2016/7. This follows the highly successful delivery of the contract for 2015/6, for which we’re very grateful for the assistance and hard work of all Sunderland practices. We will issue a revised SLA for the new financial year in due course. In the meantime, please continue to use the SLA and time commitments issued in 2015/6.”

I am sure you will all agree there has been a tremendous amount of hard work undertaken in a short space of time and I thank you all for your input and continued support.

For more information please contact Judith Taylor, Contract Delivery Manager, 0191 516 6076 or [email protected].