10. A Multidisciplinary framework for the Hospital
6.50 We have already said in paragraph 6.2 that we recommend multidisciplinary teams at hospital, clinical area and ward levels, and that apart from the Hospital Team, those teams should have a coordinating and persuasive but not managerial, role. We now develop this concept in more detail but we emphasise that what we say is not intended to be a blueprint to be slavishly followed. It is intended rather to provide a sound framework on which the Health Authorities and the hospital can build, making such alterations and modifications as seem desirable to achieve sound management of the hospital.
6.51 It will be convenient to look in turn at each of the levels at which we have suggested that there should be multidisciplinary teams. We start at ward level because our proposed structure is best explained by working up from the bottom.
A. THE WARD MULTIDISCIPLINARY TEAM
6.52 1. Composition
We suggest that this team should be composed of:
A Consultant, chosen by his colleagues
The Ward Medical Officer
The Nursing Officer
A Charge Nurse or Ward Sister, chosen by the Ward staff
A representative of Patients Activities, preferably from the Occupational Therapy Department
A representative from Patients Services should attend as necessary.
Members of the junior staff also should attend in rotation as an essential part of learning. We have no firm view on how many should attend at a time. 2. Responsibility and Task
6.53 (i) The team will have a corporate responsibility to the Clinical Area Team for coordinating the formulation and review of ward policies and standards to be agreed by all the disciplines. The matters upon which policies and standards should be agreed include:
(a) The number of beds on the ward. Admission and discharge rates. The function of the ward.
(b) A programme for up-grading, furnishing and equipment, etc.
(c) A twenty-four hour programme, i.e. time of getting up, times of meals, allocation of time to occupational therapy, social activities, etc.
(d) Off ward activities including outings.
(e) Visitors and visiting activities, including volunteers.
(f) Patients' independence, i.e. for dressing, eating, attending activities, etc.
(g) Admission and management policy for the first twenty-four hours: and, similarly, policy for discharge, including contact with follow-up and community services,
(h) The management of Violence.
(i) The handling of complaints.
(j) The management of medication, physical treatments, E.C.T. etc.
(k) The involvement of and a programme for learners on the ward.
(l) The integration of female and male patients, and the integration of staff.
(m) Housekeeping and catering services and clothing schemes for patients.
(n) Payment of patients' allowances.
(o) Procedures and management responsibilities for dealing with patients' personal possessions and security.
(p) Individual treatment programmes, procedures for recording in patients' notes and for frequency of review.
6.54 (ii) The policies and standards agreed between disciplines at ward level should be consistent with guidance given by higher authority and should be submitted to the Clinical Area Team for approval. If the Ward Team is unable to obtain agreement to a policy or standard it has recommended, the matter should be referred to the Clinical Area Team for guidance. If that team is unable to bring about the agreement of the disciplines it will refer the problem to the Hospital Management Team which, with its managerial role, will able to arrive at and require compliance with a decision. In this way policies and standards for the ward Will be arrived at, preferably by agreement, but in the absence of agreement by the decision of a Team with managerial power.
6.55 (iii) The responsibility for checking and, where necessary, correcting the performance of those responsible for implementing the agreed policies and standards will remain with the individual disciplines, but the Ward Team will have a supporting role, in that where it is informed that individuals have been unable or for any other reason have failed to fulfil their part of the agreed policy or standard, it will draw the attention of the appropriate manager in the relevant discipline to the failure, together with any view the Team may have formed. If that fails to secure compliance with the policy or standard, the Ward Team should refer the matter to the Clinical Area Team who will pass it to the discipline managers at that level, e.g. the Senior Nursing Officer. If this also fails, the problem will pass to the Hospital Management Team.
6.56 (iv) Where the inability or other failure of a Consultant to comply with an agreed policy or standard is referred to the Ward Team we: consider that it should seek help from the Clinical Area Team and the Chairman of the Medical Executive Committee. If they fail to remedy the situation the problem should be passed to the Hospital Management Team. If it fails to obtain compliance, the matter should be speedily passed to the District Management Team and the Regional, Health Authority, which is the only body able to take effective action.
6.57 (v) It will be seen, therefore, that the managerial role of the individual discipline is undiluted. A failure to Comply with an agreed policy or standard will only reach the Ward Team if there has been a failure within a discipline. Even then the aim of the Ward Team will be to encourage the appropriate manager to take appropriate action, and only if this fails will the Ward Team pass the failure to the Clinical Area Team, who in turn will seek to persuade action from the discipline in default. In this way we think that there will be more chance of managers managing, and less chance of problems getting lost or being allowed to moulder within disciplines. The mere knowledge that unsolved problems brought to the attention of the Ward Team will be minuted and if necessary passed up the multidisciplinary team ladder, will in our view be a spur to action.
3. The Team Co-ordinator
6.58 The team will require a co-ordinator who will need secretarial assistance and be responsible for:
(i) preparing agendas for and minutes of meetings: it is to him that requests should be made for an item to be put on the agenda;
(ii) reporting to disciplines any failure to Comply with an agreed policy or standard which has been brought to the attention of the Ward Team;
(iii) reporting back to the Team any continuing failure by a discipline to comply with an agreed policy or standard, and any failure by discipline to agree with a recommendation of the Team;
(iv) sending minutes of meetings to the Clinical Area Team for information, together with a separate document setting out any matters on which the Clinical Area. Team are asked to take action or give advice.
6.59 We consider that the Nursing Officer should be the co-ordinator of the Ward Team. Not only will this help him to fulfil his role, but it also recognises that it is the nurses Who provide the framework for all the activities on the ward. They should be the co-ordinators of the other services at this level. 4. A Team Chairman?
6.60 We do not consider that a Chairman is essential, as the lead in discussion will probably be taken by the member of the team whose knowledge is most relevant to the matter in hand. Each team, however, will evolve its own method of working. 5. Frequency of meetings
6.61 Once ward policies and standards have been agreed we do not envisage more than one meeting each month.
B. THE CLINICAL AREA MULTIDISCIPLINARY TEAM
1. Composition
6.62 We Suggest that this Team should be composed of: A Consultant chosen by his colleague The Senior Nursing Officer A Social Worker An Administrator A representative from the Patients' Activities Team A Psychologist should attend as required, as will others whose presence is considered desirable for the discussion of any particular matter. 2. Responsibility and Task
6.63 (i) The Team will have a corporate responsibility to the Hospital Management Team for co-ordinating agreement between the disciplines on the matters hereinafter set out in sub-paragraphs (a) to (h) and for creating and maintaining the links referred to therein and in sub-paragraphs (j) to (1). This list should be added to or otherwise varied as appropriate. (a) Approval of ward policies for the wards in the Clinical Area. (b) Provision of a psychiatric service to the Health District catchment area served by the clinical area. (c) The balance of the clinical area resources between hospital, day hospital, out-patient and domiciliary psychiatric services. (d) The estimate of requirements for the clinical area. (e) The maintenance of liaison with the other clinical areas in the hospital and ensuring that the best use is made of resources, e.g. common use of sick wards, occupational, social and recreational 'facilities. The review of policies at regular intervals. Advising the Hospital Management Team if 'hotel' and support services are at an unacceptable level. (f) The review of policies at regular intervals (g) Advising the Hospital Management Team if ‘hotel’ and support services are at an unacceptable level. (h) Ensuring that there is a planned development of community services and that the Joint Consultative Committee is kept informed of the needs of the mentally ill in the community. (i) Maintenance of liaison with the Local Authority Services of the District/catchment area served. (j) Keeping the Hospital Management Team informed of the clinical area activities and contributing to the whole hospital policy making. (k) Ensuring that communications flow upwards to the Hospital Management Team and down to the ward teams. (l) The maintenance of liaison with the Community Health Councils for the Health District/catchment area served.
6.64 (ii) If this Team fails to reach agreement with a Ward Team it has no power to compel compliance. If persuasion fails the matter must be referred to the Hospital Management Team.
6.65 (iii) The doctors in the Clinical Area, who form a Psychiatric Division under the Cogwheel structure, will continue to hold such meetings as they may consider necessary. 3. The Team Co-Ordinator and Chairman
6.66 (i) We consider that each Team should choose its own co-ordinator. He will carry out for the Clinical Area Team similar duties to those summarised in paragraph 6.58 for the co-ordinator of the Ward Team. In addition he will be responsible for maintaining the various links set out above. A full time secretary will be necessary. (ii) Each Team should choose whether a Chairman is necessary. 4. Frequency of Meetings
6.67 This must be decided in the light of experience.
09 February 2025
