Effects of multidisciplinary teams on outcomes for patients
- An overview of 34 systematic reviews found that interprofessional collaboration in primary care was associated with improvements in clinical measures (HbA1c levels and blood pressure), medication outcomes, process of care outcomes and patient satisfaction. The overview did not provide estimated effect sizes for any outcome.
- A meta-analysis of 39 studies (published after the overview) reported statistically significant reductions in HbA1c (p≤007), systolic blood pressure (p<0.001) and diastolic blood pressure (p<0.001) for patients receiving interprofessional collaboration based primary care compared with usual care.
- A retrospective cohort study from the United States (102 family practices, n=113,452 patients) reported that patients from interprofessional collaboration based primary care practices had lower rates of healthcare use, including a significant reduction in the number of primary care appointments, compared with usual care: incidence rate ratio 0.93, 95% confidence interval (CI) 0.92 to 0.94, p<0.001.
Effects of changing the skill mix within GP practices
- A large mixed methods study in England (6,296 primary care practices) explored the effects of changing the skill mix in primary care practices by one GP, nurse, pharmacist or other direct patient care practitioner.
- Adding other professions to the skill mix had a limited impact on GP workload, possibly because GPs changed to managing more complex cases and increased their supervisory responsibilities.
- GPs worked longer hours when there were fewer GPs per 1,000 patients at their practice.
- GPs reported delegating more tasks when the number of nurses and other direct patient care practitioners increased.
- An increase in the number of nurses and pharmacists per 1,000 patients was associated with quality improvements in antibiotic prescribing.
- A systematic review of 77 studies found that addition of healthcare professions to the primary care skill mix was associated with improvements in health markers.
- Expanding the range of professions in the primary care team was associated with improvements in interim diabetes markers (HbA1c, blood pressure and cholesterol), improvements in self assessed health status, and reductions in accident and emergency visits.
- A greater proportion of patients received appropriate tests and services when interprofessional collaborative models of care were applied at their primary care practice, when multidisciplinary care plans were used and when nursing professionals were added to the primary care team.
Facilitators to implementing MDT working in primary care
- Multiple systematic reviews outlined similar factors that are associated with successfully implementing MDTs in primary care:
- clear role boundaries and responsibilities for each healthcare profession
- good communication including informal chats, team meetings and information technology systems that everyone can access
- colocation of team members at a single site
- a shared vision and goals
- mutual respect and trust between professions and professionals, and
- a named care coordinator who retains responsibility for a patient’s care throughout their care journey.
Healthcare professionals’ views and experiences
- A systematic review and three qualitative studies explored healthcare professionals’ views and experiences of MDTs in primary care. Studies included nursing staff, GPs and pharmacists.
- Overall, healthcare professionals reported positive views and experiences of MDTs in primary care.
- Most professions recognised that their roles were changing as a result of implementing MDTs in primary care and generally found this to be a positive experience. Changes to the GP role resulted in a greater focus on patients with complex care needs.
- Concerns were raised about the time impact of supervisory roles on both GPs (the supervisor) and the nurses who were being supervised.
- While nurses and GPs had similar views on what was important for successful collaboration, they often interpreted these factors differently.
- MDT working reduced GP workload in some cases, but also raised concerns among GPs about deskilling.
- Some GPs expressed concern that patients did not always seem to be aware that they had seen by someone other than their GP.
Patient views and experiences
- A systematic review, a mixed methods study and an observational study explored patient views and experiences of MDT working in primary care.
- Patient views and experiences of multidisciplinary primary care teams were generally positive.
- Patients described receiving more holistic care with MDTs.
- Patients felt able to access healthcare more quickly and get longer appointments when they had a choice of healthcare professionals.
- Patients viewed care coordination as an important element of multidisciplinary primary care.
- Patients did not always understand the different roles and remits of new healthcare professionals at their practice.
- Patient trust and confidence were reduced if they wanted to see a GP but instead saw a nurse. Communication quality was similarly perceived to be reduced as a result of patients not getting to see the healthcare professional of their choice.
9. Based on a primary costing analysis using data from one health and social care partnership (HSCP), the increase in the national MDT workforce in primary care since 2018 is estimated to have saved 45,729 hours of GP time each week in 2022, equating to an avoided resource cost of approximately £6 million per week. These figures are not equivalent to net savings because they have not been balanced against the time and costs of the employed MDT workforce.
10. The cost analysis contains a number of caveats which affect the robustness of conclusions:
- MDT staff impact on GP time was based solely on information specific to the composition of the Edinburgh City HSCP
- more details about the proportion of staff on each Agenda for Change band, their working hours, and turnover rates are required in order to reliably estimate the costs associated with MDT staff nationally
- insufficient data were available to quantify other cost benefits associated with MDT working in primary care
- further information is required about the measures of variation needed to scale up the benefits observed in local practice (such as average practice list size, standard deviations and interquartile ranges), and
- more robust economic evaluations are dependent on the development of routinely collected datasets that can better quantify the overlap in clinical roles and other metrics of collaborative working, as well as supervision and learning curve effects.
What were we asked to look at
The Scottish Health Technologies Group (SHTG) was asked to assess the evidence on the impact of introducing multidisciplinary team (MDT) support in primary care, to work alongside general practitioners (GPs).
Why is this important
The 2018 general medical services (GMS) contract in Scotland proposed the addition of multidisciplinary primary care staff to GP practices and the community, to work alongside GPs and practice staff to reduce GP workload. Since then there has been ongoing implementation of multidisciplinary working under the GMS contract, with recruitment of an estimated 3,220 new primary care staff. Using this approach allows GPs to retain their role as expert medical generalists and delegate responsibility for certain tasks to other healthcare professionals within the MDT. The introduction of the MDT can help to address the increasing demands on primary healthcare from an ageing population with complex care needs.
Scottish Government Primary Care Directorate