Standard 4: Seamless planned coordinated care - Example GP Practice Team EOLC group exercise

Record: Those attended, apologies, and date of meeting

The aim

  • To confirm effective MDT structure (form)
  • To develop a robust MDT process (function) to review, make decisions, plan and support the health (and non-health) needs of patients with advanced serious illness and end of life care.


A MDT requires: 

  1. Representation from relevant disciplines
  2. Leadership
  3. Terms of reference
  4. Referral process
  5. Co-ordination and administration
  6. Access to data
  7. Outcomes monitored
  8. To be patient centred
  9. Purpose defined
  10. Specific Measurable Achievable Realistic Time based (SMART) goals


For professionals across different settings to make time to attend and contribute to a MDT, people fundamentally have to believe their input is making a difference. So if you have a combined MDT of different functions, then to avoid disengaging colleagues, it is advisable to invite the relevant team members to a distinct MDT for patients identified and on the practice 'Supportive Care Register'(name to be decided by the practice) – reviewing Advanced Serious Illness /EOLC.

This aims to give guidance on a framework to General Practice to establish high-performing MDTs.

Each practice will be unique and this does not suggest a 'one size fits all' approach and simply aims to offer guidance on a structured approach to align patient-centred care with local service delivery.

Once set up, it is easy for MDT to stagnate and not necessarily achieve the outcomes desired. Therefore, it is important to agree the right / necessary people to have in the room, agree as a team the desired outcomes and to regularly check-in with colleagues if you as a team feel you are achieving those goals.

Depending on the skill mix and collaboration between GP networks (groups of practices working together at scale), it is possible to consider MDTs at scale and the same framework can be used.


Discuss the following questions as a group (and someone take notes on the key points)

  1. Define the MDT structure (form) of your MDT
  • The Team

Core team? Who from the practice? Who from outside the practice? Suggested minimum: GP, hospice and community nursing representatives. Examples of wider representation, including virtual input and at scale, below:

MDT Structure image

  • Leadership: Who chairs the meeting? Rotating chairs?
  • Attendance: Discuss how often does (and practically can) the MDT meet? Chair to decide if quorate and sufficient representation to hold MDT
  • Governance: Is there a basic Terms of Reference for the MDT? Record of attendance for each meeting?

Meeting operation


  • How are referrals received?
  • Does your MDT use an electronic or paper-based proforma/template with required data fields, to enable quality assurance? Daffodil Standards and QOF Retrospective Death Audit
  • Who can refer in? Professionals, patients, carers?
  • How do referrals relate to identified patients on the practice's 'Supportive Care Register'?
  • How are referrals prioritised? For example, example of GSF Needs based coding: Blue (A) Year Plus prognosis Green (B) Months prognosis Amber
    (C) Weeks prognosis Red (D) Days prognosis OR coding based on priority of need for example, Red (Urgent) /Amber (Deteriorating) / Green (Stable)
  • How are medical needs considered? How are non-medical needs considered?
  • What community response is available in your locality?

Coordination and Administration

  • Who receives, reviews for completeness and collates the referrals?
  • Who records the outcomes from MDT discussion?
  • How is information coordinated back to relevant GP(s)?
  • How is key information shared with other providers and patients in and out of hours?
  • Who completes MDT template data set to enable audit and reflection?
  • Is conference technology available, for team members to call in, if required?

Data Collection and Monitoring

  • How does the MDT template data set align with national and local datasets?
  • How is key information coded? See example. Are outcomes documented in real-time?
  • How is data used to monitor and audit patient pathways locally and at scale?
  • Consider how will you know and monitor if the MDT is working well or not?
  • How regularly are MDTs reviewed to consider their effectiveness?
  • How does the practice understand what data to collect in order to measure your impact and enable business cases for further development?
  • How does the MDT routinely review and learn from deaths – expected and unexpected?
  • What criteria do you use to consider and report a death as an SEA?

Patient-centred care

  • Role of the patient, for example, how are patients informed they are discussed at the MDT? For example, written or verbal information
  • How are MDT recommendations/ information communicated back to the patient and those important to them?
  • If the patient does not have capacity, is 'best interest' consent documented to enable MDT discussion?
  • How is each patient involved in the decisions about their treatment goals, non-medical goals and care plan?
  • How do you measure patient experience for care received by patients with advanced serious illness and end of life care needs?

Agree the MDT purpose and function

Daffodil Standards MDT purpose and function image 

  1. Clarify with the team the purpose of the MDT and how it will help plan seamless, coordinated care for people identified with advanced serious illness and end of life care needs, on the 'Supportive Care Register' (name to be decided by the practice).
  2. Set clear, SMART goals/outcomes for the MDT. Discuss with the team:
  • Areas of diversity in beliefs about purpose of the MDT.
  • How does the MDT consider goals of family and carers – at diagnosis,deterioration/crisis, nearing death and after death.
  • How does the team enable efficient decision-making and information-sharing to align with patient-centred goals?
  • How does the MDT report risk or changes within 'the whole system'?
  • How does the MDT consider inequalities and strive to improve equitable care for their entire population? CQC thematic EOLC review.

3. Daffodil Standards and QOF Retrospective Death Audit: Each month (or between MDTs), consider patients who died at the MDT.

  • Is there a robust and timely way for all deaths to be documented, in a way that is accessible to all practice and MDT staff?
  • Were they identified and on the practice 'Supportive Care Register' (name to be determined by the practice)?
  • Were they expected or unexpected deaths?
  • For unexpected deaths in the community
    • What lessons can be learned from the care and deaths for the patient and for those important to them? (use each standard to consider factors)
    • In line with CQC national review, is there a robust system for the practice to assess and identify for serious incidents such as preventable deaths? What process and criteria do the practice follow to report in a timely manner serious incidents of preventable deaths? Consider complementing Serious Incident Framework. Is there a CCG/ locality/ health board wide agreed process?
  • Is there a system in place to share learning across the system?
  • How is information shared with patients and those important to them? How are they involved?
  • How will lessons learned improve future practice? Is there an action plan?

4. For expected deaths in the community:

  • Were the patient and those important to them identified on the practice 'Supportive Care Register'?
  • Did they have a Personalised Care and Support Plan? Were Five Priorities of Care for the dying met?
  • ID the carer/ those important to the deceased receive an agreed level of after death bereavement care, set by the practice?
  • Are there any opportunities for learning?
  • How will lessons learned improve future practice? Is there an action plan?

5. How do you collate these mortality reviews to form an annual analysis of deaths for the practice? How will lessons learned improve future practice? Is there an action plan?

Informing part of the evidence on standard

  • Agree form and structure of MDT meetings
  • Mechanism for review of patients on register

Next: Standard 5: Care is based on the assessed unique needs of the patient, carer and family >

QI 4: Continuous Improvement

Incorporate the use of Supportive Care Register Template to support better and consistent decision making and discussions at MDTs for patients and carers/those important to them. 
Use the same template to consider all deaths and any learning (for people identified on the Supportive Care Register and people who died but were not identified). 

If reflected on regularly at each MDT (e.g. monthly), this naturally helps the practice a) plan care and support for those identified and b) learn from deaths. In addition, the template forms the basis of a regular (e.g. annually) practice Retrospective Death Audit  (to cover an agreed time) and action taken where outcomes achieved do not meet the practice accepted standards. 

Consider continuous monitoring of template criteria e.g. preferred place of death achieved, which are plotted on a line graph monthly. Consider National Information Standard for minimum EOLC dataset.


The item has been added to your basket.

Continue shopping

Go to basket

This item is out of stock.

Continue shopping

The item is out of stock.

Yes Continue shopping

An error occurred adding your item to the basket:

Continue shopping