Hereford MS MDT Team
Wye Valley NHS Trust

Our core MS team is a community based, non-medical model, made up of two MS nurses, an MS OT, and an MS Co-ordinator. The wider MDT includes Neuro OT, Neuro Physios, SALT, and Dietician and Wheelchair services. Collaboration is at our core: when newly diagnosed patients are seen for the first appointment, we invest time in education on “what MS is” and how to “live well with MS”. This is done as a home visit, jointly with an MS Nurse and OT. We find this joint approach valuable, as it allows for a greater outcome of goals, and it has also reduced our telephone helpline/e-mail queries. From that initial visit, we pose the notion of referrals to the wider team and involve them early. The MDT team also offers education days, such as ‘newly diagnosed’ and FACETS.

In the absence of local specialist services, we have continued to work with the commissioning team to develop local approaches, such as: FES/walkaid assessment, Botox, vocational rehab, handwriting and feeding assessments, and joint physio/MS nurse home visits. Multiple Sclerosis is a progressive disease and as a team we have changed our approach to communicate when we feel our patients are exhibiting progression.

We aim to teach Persons with Multiple Sclerosis (PwMS) that early progression happens and how to recognise this. Being a non-prescribing site, we liaise with the QE Neurologists. However, we provide all the pre-screening/education and monitoring locally. We are unique in being the only community site to offer JCV testing. We offer a home phlebotomy service and arrange to go into people’s places of work to obtain bloods. We feel this is vital to support people in work, to maintain their work/employer relationship, and boost self-esteem and a sense of purpose.

To read the Judges’ Special Award case study including the solutions, results, and more. Click here and download the PDF or listen to pharmaphorum’s Deep Dive editorEloise McLennan talking with Del Thomas here.

Thank you to this year’s QuDoS in MS programme sponsors, Novartis and Roche.