Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0122The Multidisciplinary TeamHenry RosenvingeMoorgreen Hospital, Southampton, UKTeamwork in the animal kingdom is a behaviour that enablessurvival. One example of its success is the male emperor penguin,who incubates his precious single egg balanced on his feet for 60days through the total darkness of the Antarctic winter. This deedis achieved by the emperors huddling together and shufflingaround in a constant movement, providing ever-changing relieffrom the gale-force wind 1 .The ability to behave in such a team has evolved throughgenerations of practice. In care of the elderly in humanpopulations there has been no such tradition and, for thosesuffering from psychiatric illness, the need for effective teamworkwas never more urgent. The problem list presented by thefunctionally or organically ill elderly patient is often disconcertinglylong and complex. The psychiatric disorder cannot beisolated from physical health problems, neither can the patient’sfunctioning be assessed outside the context of his/her owndomestic and social situation. Thus, in attempting to treat thepatient it is necessary to combine the skills of psychiatric andgeriatric medicine, together with those of nursing, clinicalpsychology, remedial therapy and social work. In many situations,input from the Housing Department, voluntary agenciesand the local chaplaincy will be required. The creation ofcommunity care packages defined by the UK GovernmentWhite Paper, Caring for People in the Next Decade and Beyond,highlighted the development of teamwork in case management 2 .The UK Government has extended this strategy to include carersas partners of professionals in the planning and delivery of care 3 .Teamwork in the management of the detained patient, particularlyin respect of discharge planning and aftercare, arerecommended as good practice by the Department of Health 4 .No one profession can attempt to provide all the various skillsnecessary in the management of every case. It is the relationshipbetween the different professions that is so important. Theconcept of the multidisciplinary team can be described as agroup of members of different professions whose working skills,when combined for the needs of the patient, aim to exceed inquality the simple summation of their individual abilities. Teamworkadds that extra vital ingredient, which needs furtherexploration.The multidisciplinary team should be restricted in size to thosepersonnel actively involved in management of cases and in closegeographical proximity, to enable face-to-face contact betweenworkers. However, the team should not exist in isolation fromother services. The services that collaborate most successfullyinternally have been shown to not necessarily work best withother agencies 5 . Between different agencies there should be formalliaison and agreed policies over borderline cases and servicedemarcations.FEATURES OF SUCCESSFUL MULTIDISCIPLINARYTEAMWORKCommunicationThe Personal Social Service Council, in its review of communitycare, found that failures in communication and negotiation withother agencies led to ignorance of the roles and skills of otherprofessional groups. The organization of care was less good in themore complex situations. As a result, wrong courses of actionwere taken by some professionals, including inappropriateadmissions to both hospital and residential care. The need forjoint planning was stressed, particularly between professionals ofthe different agencies at the operational level 6 . Effective communicationis grafted onto the rootstock of mutual trust and respectfor the individual roles and skills of other team members.Autonomous decisions, unnecessary duplication of work andstereotyping of one professional by another are thus avoided.It is important that communication within the multidisciplinaryteam is afforded formal expression in regular meetings. Too much‘‘corridor’’ decision making can lead to mistrust. Regularattendance by all personnel complements the identity and strengthof the team. This results in the creation of a suitable arena for theairing of grievances and resolving of disputes. Teamwork involvesallowing the patient and carer to participate in the process. Thetherapeutic team could include the patient 7 , although the currentclimate of consumerism in care might be perceived as threateningby some workers.LeadershipTraditionally, the leadership role in health care is assumed by thesenior doctor; this in part reflects society’s expectations and faithin the medical profession. Treatment directives may be instigatedby the initial medical assessment and form the basis for theleadership role in the clinical team. The dominant role of thedoctor in the healthcare team may have a stabilizing effect onthe team’s structure and prevent leadership struggles by othermembers 8 . Too hierarchical a structure, though, will result in toomany decisions made by one person. More democratic teams willdevelop more flexible work practices and collective decisionmaking. The doctor may in fact be the least qualified inmanagement and leadership skills within the team. Moreover,the reason why multidisciplinary teams can work so badly isfrequently the scant regard paid to them by the medicalprofession. Non-medical leadership of the multidisciplinaryteam can work, particularly if the issue of responsibility forPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd