MDT Consent Form

Patient Consent Form
for sharing information at multi-agency multi-disciplinary team meetings (MDTs).

Note to referrer: Please give this form to the patient along with the information leaflet (appendix 7) On completion please attach to the patient record.

Your Name / Your NHS Number
Your Date of Birth / Date
I have read and understand the information provided on this form. / Please tick:
I would like some more information.
(Please indicate below what you would like more information about.)
Please complete the following consent form:
Part 1: For your care to be discussed at a multi-agency multi-disciplinary team (MDT) meeting
i) I agree to my personal information, care and treatment being discussed at multi-agency multi-disciplinary team (MDT) meetings.
Circle as appropriate: Yes No
ii) I agree to information about me and my condition(s) being shared with other care organisations, not currently involved in my care, which may attend the MDT.
Circle as appropriate: Yes No
iii) Exemptions - I do NOT agree to information about me and my condition(s) being shared with the following individuals or organisations. (Please list any organisations or individuals you do not wish us to share your information with. You do not have to give a reason for this.)
Part 2: For additional information about you and your care to be recorded on a Summary Care Record
I give consent for additional information to be added to my Summary Care Record. This may include information detailing any health issues which my GP and I consider to be important to my wellbeing. I can change my mind at any time by notifying my practice.
Circle as appropriate: Yes No
Part 3: For anonymised information to be used as part of service evaluation.
I agree to anonymised information about my condition, experience and wellbeing to be shared to help inform evaluations and future service developments.
Circle as appropriate: Yes No
If you are satisfied with the above, please print and sign below:
Print name: ______
Signed: ______Date: ______
If the person is unable to sign but has given consent, please indicate and sign:
Witness Name:______Signature ______
Relationship: ______Date: ______

Mental Capacity Act

The Mental Capacity Act sets out the definition of a person who lacks capacity.

The Act says that a person lacks capacity if they have a temporary or permanent impairment of/or a disturbance in the functioning of the mind or brain when the decision needs to be made, and as a result is unable to:

  • Understand the information relevant to that decision
  • Retain that information
  • Weigh up information as part of the process of making the decision or
  • Communicate their decision (whether by talking, using sign language or any other means).

Where the person lacks capacity and is unable to consent, and there is no registered Lasting Power of Attorney or Deputyship for health and welfare decisions, information can only be shared after an assessment of capacity and subsequent best interest decision, following adherence to the principles of The Act.

Further guidance on The Mental Capacity Act 2005 is available from www.gloucestershire.gov.uk/health-and-social-care/adults-and-older-people/mental-capacity-act-2005-multi-agency-policy-procedure-and-guidance

If the person named overleaf lacks the mental capacity to either give or refuse consent is there another person who holds formal decision making
responsibility? If yes please supply details below:

Name ______Relationship______

Address______

______

Telephone Number ______

Does this person hold (delete as appropriate):

  • Lasting Power of Attorney (for Health &Welfare or Property & Finance)
  • Deputy Welfare
  • Enduring Power of Attorney

Patient information about consent

What is the purpose of the consent form?

This consent form enables you to give explicit, informed consent for:

1) Your care to be discussed at a multi-agency multi-disciplinary team (MDT) meeting

2) Additional information about you and your care to be recorded on a Summary Care Record

3) Anonymised information to be used as part of service evaluation

What is a multi-agency MDT and what will it do?

A multi-agency MDT meeting brings together professionals and services involved in your care to help ensure that we are providing joined-up care for you. We may need to share your information with other organisations which are not currently involved in providing your care and support. Based on shared information about your current condition and circumstances, the team discusses treatment or care options and makes recommendations that might improve your care or circumstances.

Who will be part of the MDT?

Depending on your individual care, this may include, but is not limited to:

  • GPs and Specialist Doctors
  • Community and Specialist Nurses
  • Occupational Therapists
  • Physiotherapists
  • Pharmacists
/
  • Mental Health workers
  • Paramedics
  • Some administrative staff
  • Social care staff
  • Social prescribers

Why does an MDT want to discuss patients?

Sometimes when people have complex care needs or are seen by lots of different services, their care can become uncoordinated and communications can be missed. To avoid this, your GP, or a professional you know, will talk to you about the MDT and find out if you have any personal goals or concerns about your care. Any recommendations made will be discussed with you. You, and anyone who supports you, will decide whether you want to include these as part of your personal care plan.

What information will be shared?

The information we may need to share includes, but may not be limited to:

  • your name, date of birth and unique NHS number
  • your health symptoms and personal circumstances
  • your personal goals

This information is needed in order to fully understand ongoing difficulties you might be experiencing. Only information which is relevant to your condition and care will be shared at the MDT.

Isn’t my information already shared by care providers in Gloucestershire?

Limited information is already shared between your GP and other providers directy involved in providing you care and support. Information is not available to people working in other parts of your local NHS and care community unless you provide explicit consent.

The Summary Care Record (SCR) is an electronic record which only contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. It also includes your name, address, date of birth and unique NHS Number, which helps to identify you correctly.

You can choose to have Additional Information added to your Summary Care Record (SCR-AI) by your GP practice. This is a summary of information about your medical history and care plans whichcan be of particular benefit to individuals with detailed and complex health problems. Only authorised healthcare professionals directly involved in your care can access your SCR-AI. Other services, such as urgent care services or hospitals, can access your SCR-AI only when you give consent.

Additional Information can only be added with your explicit consent and can include information about the following:

  • Your long term health conditions, such as asthma, diabetes, heart problems or rare medical conditions
  • Your relevant medical history, such as clinical procedures that you have had, why you need a particular medicine, the care you are currently receiving and clinical advice to support your future care
  • Your healthcare needs and personal preferences, for example, you may have particular communication needs, a long term condition that needs to be managed in a particular way, or you may have made legal decisions, advanced decision or have preferences about your care that you would like to be known

Please note: specific sensitive information such as any fertility treatments, sexually transmitted infections, pregnancy terminations or gender reassignment will not be included, unless you specifically ask for any of these items to be included.

How else may my information be used?

To ensure that we provide appropriate services, we use anonymised data to evaluate how we are doing, make improvements, and help us plan future services. This will not identify you personally and will enable us to understand the service more generally. To use this anonymised information, we need your explicit consent.

How will my information be protected?

All organisations, agencies or individuals involved in your care are required to abide by strict codes of conduct on security and confidentiality, including Sharing Information Protocols.

When considering who may see your information, our staff use the following principles as set out in the Data Protection Act 1998, to:

  • Only share information with those who need to know in order to provide good quality care
  • Share the minimum information necessary to ensure the good quality care

Can I change my mind and withdraw my consent?

Consent to share information should be reviewed on a regular basis as agreed with you. If there are any changes to be made, a new form should be completed to reflect your wishes. (If you are incapable of giving consent, the review may be made by the health professional responsible should they feel it is necessary and in your best interest to do so.)

MDT consent form and information sheet FINAL 2.7.17 1