Multidisciplinary teams (MDTs)

A Multidisciplinary Team (MDT) is a group of professionals from different disciplines—such as GPs, nurses, therapists, pharmacists, social workers, housing officers, and voluntary sector partners—who work collaboratively to plan and deliver coordinated care for individuals, particularly those with complex needs like frailty or dementia

Multidisciplinary teams (MDTs) can be an effective tool to facilitate collaboration between professionals and hence improve outcomes for people and communities. MDTs should proactively consider how to involve individuals and families to ensure that their views and interests are kept at the centre of decision making. Successful MDT working requires facilitative leadership, equality between members, encouragement of constructive challenge, and common access to information.

How MDTs Work in Gloucestershire

MDT working is embedded across the system through:

Virtual ward rounds and Cinapsis for real-time collaboration
Integrated neighbourhood teams that include frailty matrons, dementia specialists, and adult social care navigators
Shared digital care plans and whiteboards to track patient needs and interventions
Proactive screening and segmentation using tools like Brave AI and risk stratification dashboards

NHS England and Health Education England promote MDT working as a key enabler of integrated care. The HEE MDT Toolkit provides a step-by-step guide for building effective MDTs, including:

Shared goals and culture
Skill mix and role clarity
Communication and information sharing
Continuous evaluation and improvement

Multi-agency working: Multi-agency working is where professionals from different agencies collaborate to achieve a joint mission. Multi-agency working allows practitioners to evaluate an individual’s issues from multiple perspectives rather than focusing on a specific area.

Multi-Agency Partners in Gloucestershire Frailty Services