Video: how our multidisciplinary team works

This video is an interview with our clinical leadership team, GP Dr Rachel Duncan, Consultant Psychiatrist Kristina Antonova, and Consultant Psychiatrist Victoria Lukats. They give an overview of how the multidisciplinary team (MDT) works in the Brighton and Hove Memory Assessment Service (MAS) model.


Video transcription

TITLE: Meet our clinical leadership team

Rachel: So I’m Dr. Rachel Duncan. I’m a GP and I’m one of the clinical leadership team here in MAS.

Kristina: My name’s Kristina and I’m a consultant psychiatrist.

Victoria: I’m Victoria Lukats. I’m a consultant in Old Age Psychiatry and I work at the Memory Assessment Service in Brighton and Hove.

Rachel: I’ve held quite a lot of different roles during my life as a GP.I’ve worked as the roving GP in Brighton and Hove for over ten years, which is admission avoidance mostly for housebound elderly patients. I’ve also held roles with the commissioning team in mental health in the past and at the moment my predominant role is here at MAS as one of the clinical leads.

Kristina: I’ve got several functions in MAS, I think. I’m part of the MDT – that’s a multidisciplinary team, so I work collaboratively with memory support workers, with nurses, with GP’s and I support the clinical team to make diagnoses, to help assess people coming through our service. I support people in starting treatment and continuing on with the treatment, but I’m also there really for the more complex presentations and if they need a consultant psychiatric opinion and assessment.

Victoria: I specialise in seeing people with dementia or going through the dementia diagnosis pathway. And alongside that I also work in an acute hospital in Sussex seeing people with dementia who are admitted to a hospital.

And in the past I’ve also had roles as Clinical Lead for Dementia Services in Sussex Partnership NHS Foundation Trust, and I’ve also been the Associate Clinical Lead for Dementia for the South East Coast Clinical Network for NHS England, where I was involved in supporting commissioners of services to make new memory assessment services and bring up dementia diagnosis rates in their areas.

TITLE: A service modelled on patient needs

Rachel: In MAS, when we did our redesign work in 2016-17, we identified that what was going to be fundamental was support at the front door, that we felt that our patients were unique and we developed a bespoke service for them that followed them right from the beginning of their journey with MAS and all the way through if they received a diagnosis and continuing on as now a lifelong service of support.

So fundamentally the support pathway and the clinical pathway are completely intermeshed and intertwined. So we have no separation in that if our support workers have concerns about a patient they’ve been dealing with or family members have questions we can find out about those, and deal with it straight away in an interconnected way. We all share the same information. So it really is for the patient a very bespoke service for them as an individual.

TITLE: The role of the multidisciplinary team

Rachel: If needed, we have very quick access to head scans – so an MRI or a CT. And the next stage for the patient will be at our MDT stage. At MDT, it is a meeting that’s held to go through all the history, look at all the tests that we’ve done and look if there’s a scan together to try and come up with a diagnosis for what we think is causing the patient’s difficulties. So at the MDT, there will be a psychiatrist – consultant care of the elderly psychiatrist, there will be GP’s with extended interest, who’ve often mostly being working within the service for several years and our nursing team.

And then following that we will look very closely at all the information we have about the patient, try and come up with a diagnosis if we feel we safely can, and then the nurse who initially saw the patient will deliver the diagnosis. So they have that continuity, they’ve already met before, it’s nice that they can kind of complete all of the assessment process with the patient and deliver the diagnosis as well.

TITLE: Better experiences for patients

Kristina: Working within MAS, what we are able to do is right from the beginning of the patient coming through our doors is try to get to know them and their support needs, or what their priorities are and whether they need other support through other services. And we do that right from the moment of receiving that referral.

So patients have what we call a first contact call from our memory support workers who understand the patient journey and understand dementia and understand perhaps the anxieties or fears a person is having when they come to our service. So we have that right from the beginning, and then we keep the communication open so that the patient, the person, and their carer or family member know how to contact us.

TITLE: Personalising how people access the service

Kristina: We work in a city and we have different places where we see people so we can try and make it as accessible as possible to that person. So sometimes we see people
in their own homes if they have additional needs or are unable to leave their home. We see patients in GP surgeries.

And I think people accessing health services want it to be easy, or as easy as possible. They want to know who they’re seeing. They want to be reassured that their concerns are taken seriously and know that they have access to other services or professionals. So I think that’s what MAS can do and is doing through its offer of the Memory Assessment Service.

I think what MAS does really well is listen to people. And that’s both listen to its staff and its clinicians, but also, more importantly, listen to the patients and people using their services. And we have patients embedded into our service and we want to know how people experience our service, and if we’re doing anything that needs improving on or changing, we will absolutely want to know about that and listen and act on it – and we have done.

TITLE: Key performance indicators demonstrating quality

Victoria: If they choose to take up the appointments that they’re offered, that might be quite, quite soon after they’re referred, if they access all the scans and the appointments as they’re offered and don’t want to delay it for any reason, they typically get a diagnosis within about six weeks of being referred by their GP [pre-COVID timescales]. Which allows enough time to have a scan, find out what that person’s might need and what support they might need, and also have a very thorough assessment with the clinicians and have access to the post diagnostic support.

The quality of life for people living with dementia who are diagnosed by our service, some people might be surprised to hear that the quality of life often improves after a diagnosis of dementia because it actually can be a very difficult condition to live with. Some people find it can be challenging. Some people find that they need extra special support after they have a diagnosis. But if you’re referred to our service, we expect about 75% of people will report that either their quality of life has stabilised or actually improves after their diagnosis.

And finally, I think we’ve made a big difference in the local area in Brighton and Hove about bringing up the dementia diagnosis rates. So by dementia diagnosis rates, we’re talking about the proportion of people in our local area who have dementia, who have have the correct diagnosis recorded on their clinical notes.

And so if we go back to before our Memory Assessment Service launched in 2013, our diagnosis rates for dementia in Brighton and Hove were sitting in the low 30s – about maybe 33%, 34%. And just before the COVID pandemic started, we recorded that about over 70% of people now with dementia living in the local area have that positive diagnosis recorded, which is quite a high level actually compared to other areas in the country. And that is primarily because of the diagnoses made through the Memory Assessment Service.

TITLE: The positive impact our our approach across the wider system

Victoria: Outside of my role in the Memory Assessment Service, I also work in an acute hospital, seeing people in the acute trust who are admitted with medical problems, who also happen to have a diagnosis with dementia.

And I feel that when people have their diagnosis, when they’ve been seen by the Memory Assessment Service and they have the right support in place, I feel generally that if they do have to come to hospital for any reason, perhaps they might have had pneumonia or they’ve had some sort of infection, I think they get out of hospital quicker.

I feel that when people have got undiagnosed dementia and very significant care needs, but those needs have perhaps not been met, they’ve had difficulties at home, but that have gone under the radar and haven’t been really known mental health services or dementia services, I feel that they can then come into hospital and be in hospital for a very long time, which is really distressing for them.

So I have seen actually firsthand many, many times that when they’ve had the right support in place from the outset, it makes a big difference. I think it probably delays people having to need to move to nursing homes. I think it means people perhaps don’t come into hospital as often as they as they would because their health needs are being met.

And I think that can only be a good thing for the wider NHS, but especially for the people living with dementia, and their carers.

TITLE: A good service redesigned to be rated outstanding by CQC

Rachel: So we were really delighted to receive the outstanding stamp from the Care Quality Commission, the CQC, a few years ago. And I think when it comes to the reasons that we were able to achieve that, it’s the whole team effort really.

I think that looking at our model and looking at the systems that we put in place, I think impressed them – the way that we view risk, and the kind of continuity of care that the patients get through our service I think also put us in a good position to achieve the outstanding CQC rating.

Kristina: When I think about MAS, I think is it a service that I would be happy my relative or my parents accessing, going through and being supported by?

And without a doubt I say yes.

And then I think, why is that? Why am I so happy with this model and why would I recommend it to the wider system?

And I think that there are many answers to this. And one is that I know that right from the beginning you get a very personalised service, right at the front door from the moment of receiving the referral, it’s the first contact that you have with our service, we’re interested and engaged with the person coming through.

We want to know about them and their story.

Victoria: One of the things I’ve been quite impressed with actually working at Here is that this is a service that if someone gets a diagnosis of dementia or maybe even mild cognitive impairment, they can be confident that it’s not going to just be a diagnosis and then be discharged back to their GP. They’re going to get what is the really important thing, which is support after their diagnosis.

So they might access groups for people that are going to be having a similar problem and they can have support in how to deal with their dementia, perhaps advice on accessing local services, it might be financial advice or practical things that need to be sorted out.

Rachel: For me as a clinician, it’s very satisfying to work in this particular type of way because I feel that it is a holistic approach.

You know, when we work with people who have dementia, we don’t have a wonderful solution to the nature of the condition, but we can very much promote people to and support people in living the best life that they can with this condition.

And also accepting for our patients that this is often one condition and they may have many other chronic conditions that they may be living with over a number of years. And we certainly want to support them in living well with dementia if that’s the diagnosis they end up getting.

And I think that it’s very satisfying as a clinician to work in a system like that where what’s best for the patient is at the heart of what we do. It’s an individual based model, so what one person might need may be very different from somebody else.

So to work in that model, knowing that it’s a wraparound service that covers all the different areas of the patient’s life in an individual bespoke way is just so satisfying.

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