Multidisciplinary team (MDT) meetings: May 2026

MDT meetings provide proactive, coordinated and person centred community health and social care for people living with frailty in South Ayrshire. The meetings have improved outcomes for patients, working relationships for staff and reduced pressure on other parts of the system.

South Ayrshire HSCP were part of the Focus on Frailty programme from May 2023 to March 2026.

Situation

In South Ayrshire 26.6% of the population is over the age of 65, compared to a national average of 20.1%. This is expected to increase by a further 6.7% by 2028 (Public Health Scotland, 2025). In order to meet the needs of this population, South Ayrshire HSCP developed an Ageing Well Strategy in 2024. The strategy covers prevention and early intervention in the community through to hospital care. There is a strong emphasis on local multidisciplinary support.

The strategy aligns with Getting It Right For Everyone (GIRFE), Scotland’s approach to designing and delivering public services that focus on people’s needs. South Ayrshire HSCP have been addressing frailty as part of the GIRFE work. Focusing on proactive, co-ordinated, person-centred community health and social care. This work links to the foundations for community frailty services paper published by Healthcare Improvement Scotland in 2025.

Following staff engagement and scene setting, South Ayrshire HSCP made improvements to their MDT meetings to ensure that all relevant professions were represented.

Approach

Weekly ‘team around the person’ MDT meetings were established in Troon and Prestwick locality in Autumn 2024 and expanded to Maybole and Girvan locality in Autumn 2025. The meetings are held virtually via MS Teams. The aim of the MDT meetings is to create a more joined up way of working for people with complex needs. This includes people identified as living with moderate to severe frailty. These meetings bring together health and social care professionals from across South Ayrshire. The MDT consists of allied health professionals, social workers, pharmacists and nurses. GPs and specialist services are invited to attend virtually at points during the meeting to discuss specific cases as required.

Identification of patients for the MDT meetings is through a mix of clinical judgement, referrals and screening by community nurses using the clinical frailty scale (CFS). An average of 14 cases are discussed at the MDT meetings in Troon and Prestwick locality each week. For discussions related to people identified as living with moderate to severe frailty the agenda focuses on identification, assessment and a coordinated approach to care planning. Meetings are co-chaired by the principal social worker and clinical nurse manager, strengthening a locality approach for integration of health and social care. The meetings allow for shared decision-making and collaborative input from a range of health and social care professionals. An appropriate professional is identified as the key coordinator of care for each individual discussed. A person-led care plan is then developed with the patient. A record log is completed to capture key activity from the meetings and shared with MDT members in a private MS Teams channel. This has helped to overcome challenges associated with different IT systems. An MDT summary is also recorded within health and social care IT systems, including general practice.

Impact

The MDT meetings have had an impact on patients and their families, staff and the health and social care system in South Ayrshire HSCP.

Patients

Patients are receiving timely, coordinated and consistent care.

  • 491 case discussions at the weekly MDT meetings in Troon and Prestwick and Maybole and Girvan localities (June 2024 to March 2026).
  • 73% of people aged 65 and over (244/335) who were referred to the district nursing service and identified as living with severe frailty, including one or more significant frailty syndromes, received a comprehensive assessment by an advanced district nurse specialist, delivered as part of an integrated MDT approach across the Troon and Prestwick and Maybole and Girvan localities (November 2024 to March 2026).

An example of a positive outcome for one patient and his family is Derek. Derek is a 58-year-old man with Downs Syndrome who was admitted to hospital with aspiration pneumonia. Following a six-week stay his family were advised that he may be approaching the end of his life. His family chose to bring Derek home to support him there. A district nurse played a key role in coordinating his care, working alongside a range of health and social care professionals. Following a period of rehabilitation and support, Derek is now doing well and enjoying a good quality of life. Derek’s sister, Lesley, shares her reflections on the MDT approach:

Quote / Testimonial:
 “Communication between the different services was excellent. Everyone understood Derek’s total care needs. They knew where everything was at and how their input affected, complimented and depended on what other services were doing.”
Derek’s sister

Learn more about Derek’s story in this YouTube video.

Staff

Relationships and communication between health and social care professionals have strengthened. In some cases, staff have been able to carry out joint home visits, reducing duplication and improving efficiency. MDT meetings have provided reassurance to team members, enhancing professional confidence and supporting decision making, which in turn contributes to improved patient safety. GPs can attend to discuss specific cases when required, meaning they do not need to be present for the entire MDT meeting, helping to optimise their time. Staff have also developed a greater understanding of policies across different professions, enabling more informed and appropriate referrals.

Results from a staff survey completed in March 2026 conclude that:

  • 75% of respondents strongly agree the introduction of a weekly MDT has had a positive impact on the people supported within the locality.
  • 60% of respondents strongly agree the MDT has improved their knowledge of the roles of other professionals.
  • 75% of respondents strongly agree they feel more confident their role, knowing they have support from the MDT to manage risks to the individuals they support.  
Quote / Testimonial:
“I think the joint working is good to allow all professionals to have a say in the best solutions for the person, makes it feel like a whole systems approach and not just been put onto one team.”
MDT member

System

There are early indications of a reduction in crisis episodes, GP visits, and hospital admissions among people identified as living with frailty. The data suggests a decrease in crisis responses, including adult support and protection (ASP) interventions for vulnerable adults, likely linked to early intervention and proactive discussions within the MDT. With more time it may be possible to establish a direct causal relationship.  

An important factor in the success of the meetings has been strong leadership, with a clear focus on quality improvement and staff engagement. This has helped embed a culture of shared risk, strengthened local relationships, and supported continuous learning and development. Quality improvement approaches, alongside targeted staff engagement activities in addition to the MDT meetings, have been instrumental in maintaining momentum and driving sustained improvement across teams.

Next steps

The team in South Ayrshire HSCP are working to improve data collection to assess the impact of MDTs on crisis episodes, GP visits and hospital admissions. MDT meetings are now well established across localities within South Ayrshire, including Ayr central, with the model being adapted to support a larger population.

Further information

To find out more about South Ayrshire HSCP’s approach, or to join the frailty learning system, please email: his.frailty@nhs.scot.

Further information and updates on the Focus on Frailty programme are available on our webpages.   

Further reading

References

  1. Public Health Scotland. Locality profile, Ayr south and villages locality. 2025 [cited 2026 Jan 15]; Available from: https://hscp.south-ayrshire.gov.uk/media/14525/Ayr-South-and-Villages-Locality-Profile-Public-2025/pdf/Ayr_South_and_Villages_-_Locality_Profile_-_Public.pdf?m=1742230668517.