Mohammed T. Abou-Saleh

668 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdecisions is satisfactorily addressed. A major DHSS document isclear that a consultant may not be held responsible for negligenceon the part of others, simply because he is the ‘‘ResponsibleMedical Officer’’. It states he is not accountable like a militarycommander; ‘‘the multidisciplinary team has no commander inthis sense’’ 9 . There is, however, a tendency to equate responsibilitywith out-of-hours accessibility, especially during a crisis.It is important to remember that the key worker may not be thesame person responsible for providing alternative care in the eventof a crisis; e.g. the community mental health nurse (CMHN) maybe the link with the elderly person at risk, but is unable to accessdirectly residential care facilities should they be needed urgently.For whoever dons the mantle of leader, skills in communicationare a vital requirement, as is the ability to create a feeling ofmutual trust and respect in order to maximize members’ strengthsand create compromise between individual members to fit in withoverall team goals. Much of the motivation for the team willdepend on the qualities of leadership. The creation of realisticgoals gives a sense of purpose and a framework. Obviously,resource constraints are a major barrier to this process. It isimportant to distinguish the demands of budget holding fromclinical management, and where the multidisciplinary leader isalso the budget holder, the team members will need to learn thewider issues in the face of restrictions caused by tight fiscalcontrol. They will need to feel the leader’s commitment andsincerity in the care of their clients or patients.AuditThe Department of Health encouraged medical audit as a meansof improving service delivery and management 10 . Care of theelderly psychiatrically ill requires more complex assessment thanpure medical audit, and the multidisciplinary team is in the keyposition to instigate clinical audit because of its potential forknocking down interprofessional barriers and prejudice. Multidisciplinaryaudit can be attempted if the process is viewed from apositive and non-defensive position. Good and bad practices inliaison will be easily revealed, particularly if the patients’ andcarers’ views are included in outcome measures. The team shouldbe in a constant state of evolution and be able to incorporate newideas. This sense of objectivity and self-assessment will be createdby a positive clinical audit programme and will itself become partof the quality of the successful team.MoraleClearly, morale is dependent on the key issues—leadership,communication, achievement of goals and self-assessment,described above. Other ingredients need adding to the recipe.Morale relies heavily on personal support and encouragementwithin the team. Through time, most team members experiencestresses and problems, which may affect their judgement andpossibly their self-esteem. This support may be available discreetlyor offered more formally through staff groups and supervision.Whatever its form, its value is its ready accessibility andconfidentiality.The ability of the team members to see the funny side of asituation is often a vital component in the maintenance of morale.Involvement in non-clinical activities, such as fundraising orgames matches against other units, may have positive effects onmorale—even in defeat. In essence, it is important to create inteam members a sense of personal value and ownership of theirteam. In the current climate of health service reorganization andcost–benefit assessment, the sharing of successes in patienttreatment can contribute greatly to good morale.FUTURE DEVELOPMENT OF THEMULTIDISCIPLINARY APPROACHThe introduction of goal-orientated multidisciplinary methods oftreatment require changes in structures of healthcare organization11 . Sadly, the move towards care management detailed inCaring for People in the Next Decade and Beyond 2 has not beencomplemented by sufficient funding to meet the requisiteplanning, training and research needs. Either the resources arenot available to get multidisciplinary teams properly established,or there is insufficient funding to achieve even modest treatmentgoals. It is disputes over limited funding that can lead to thebreak-up of collaboration between agencies and effective teamwork.PlanningThe last decade has, however, seen an encouraging trend in thesophistication of expertise within the psychogeriatric team,producing greater quality of care of the elderly psychiatricallyill. The CMHN has developed roles in early case assessment andliaison with associated professionals. Because of the high profile inthe locality, the CMHN has forged links with many agencies, e.g.district nurses, specialist housing, residential care facilities, andfacilities for the treatment of alcoholism. Together with theincreasingly skilled work with dementia sufferers, functionally illpatients and carers, the CMHN now brings to the multidisciplinaryteam a more vital and complex role. The socialworker is still not given sufficient time to use her training incasework from the all too demanding accommodation-findingrole. Historically, the champion of patients’ rights, the socialworker, may now access independent advocacy schemes. The rolesof the occupational therapist and physiotherapist have beenfurther strengthened by their involvement in community assessmentliaison. The clinical psychologist finds much demand withinthe team, not only for assessment of areas of cognitive deficit inthe patient, but also increasingly for the treatment of functionaldisorder, e.g. cognitive therapy and the evaluation of staffmanagement methods and attitudes. There remains a paucity oftraining places in clinical psychology.The shifting nature of the multidisciplinary team approach isfurther advanced by the recognition of the increasing role thevoluntary sector can offer, both informally, using volunteers asbefrienders of the patient, and more formally by such organizationsas Age Concern and the Alzheimer’s Disease Society,providing essential services such as day care. The role of thecoordinator of such services can play an important part within themultidisciplinary team 12 .The expanding therapeutic team must recognize the problemsthat may arise when a new worker comes to fill a specific rolecarried out more generally by other workers, e.g. a social workerbeing appointed where previously much informal casework wasconducted by the CMHN. Members of smaller teams may appearto have less distinct professional roles. Concentration onindividual strengths, not weaknesses, will enable expansion ofthe team to take place.TrainingIt is not clear that such growth in individual professional expertisein care of the elderly psychiatrically ill has been matched by therequisite training in multidisciplinary teamwork skills,particularly in undergraduate medical education. The GeneralMedical Council, in its publication, Teaching Tomorrow’s Doctors,has recognized this shortfall 13 . Attitudes and techniques in