Age and Ageing 2006 35(4):339-341; doi:10.1093/ageing/afl026
© The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Intermediate care in England: where next?
John Young1 and
Jan Stevenson2
1 Academic Unit of Elderly Care & Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, St. Luke’s Hospital, Bradford BD5 0NA, UK
2 Health and Social Care Change Agent Team, Department of Health, Wellington House, London, SE1 8UG, UK
Address correspondence to: J. Young. Tel: (+44) 01274 365311. Email: john.young{at}bradfordhospitals.nhs.uk
Keywords: older people, community services, intermediate care, elderly
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Introduction
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The announcement that the stipulated targets for intermediate
care have been met marked the end of the beginning for this
new type of community service in England [
1]. The targets, which
quantified people treated and places and beds available, have
not been a popular indicator with service providers. They have
proved difficult to collect, partly because of the potential
for double counting of shared social and healthcare services
and partly because of uncertainties in accounting for patients
moving between different intermediate care services. Moreover,
there has been considerable scope for simple re-badging of existing
services as intermediate care. Nonetheless, this rapidly achieved
landmark will be closely observed by healthcare planners internationally
who are similarly wrestling solutions to demographic transitions,
acute care demand and the burdens of chronic disease. It is
therefore opportune to draw back and consider the reality of
progress to date and reflect on the future of intermediate care.
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Background
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The roots of intermediate care lay in the recognition that acute
hospital care was a blunt instrument for chronic disease management,
that there was insufficient time available for the process of
rehabilitation and functional recovery for older people and
that community care as a patient experience in England was one
of organised chaos. The concept of intermediate care was first
signalled in the National Beds Enquiry [
2] and became policy
in the NHS Plan [
3], and a rapid national dissemination was
achieved through the National Service Framework for Older People
[
4]. Initial responses were mixed and included those of suspicion
[
5], a concern about the re-invention of workhouses [
6] and
a judgement that an evaluation was urgently needed [
7]. There
was much introspection over competing definitions and understandings
of intermediate care. Indeed, the concept and its taxonomy continue
to excite academic debate [
8]. The national targets cleverly
cut through much of this debate by imposing a highly practical
definition for intermediate care [
9] that, although in some
respects restrictive, has allowed sufficient flexibility in
interpretation to foster local innovation and service diversity
[
10]. At a time when the Department of Health has been concerned
with local devolution of healthcare planning, with reluctance
to issue central guidance, it is perhaps salutary that such
a clear statement of what is, and is not, intermediate care
has been so helpful. Few can doubt that the national targets
have achieved their objective of a rapid expansion of intermediate
care services, though the journey has been hard won [
11] and
general practitioner engagement remains weak [
12].
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What has intermediate care achieved?
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The strategic aims of intermediate care were concisely stated:
‘ . . . to promote faster recovery from illness and prevent
unnecessary acute hospital admissions, support timely discharge
and maximise independent living’ [
4]. Thus, there was
an expectation that general hospitals would become less hard
pressed and that admissions to (expensive) institutional care
might be avoided. The extent to which these aims have been achieved
is unclear. Despite a specific obligation for primary care trusts
to reduce acute admissions, general hospitals nationally continue
to be hard pressed, and Department of Health episodes of care
statistics reveal there has been a further 7.8% increase in
acute admissions since intermediate care has been a healthcare
policy. There has been greater apparent success with expediting
hospital discharges. Delayed discharges have fallen in the 3
years since 2001 from 6,419 to 2,619 [
1]. Although it is likely
that intermediate care has contributed to this welcome improvement
in bed management, the issue is a complex one and includes other
factors such as better co-ordination between health and social
care following the introduction of the reimbursement policy
[
13]. The effects of reimbursement on the process of hospital
discharge is illustrative that in a turbulent, constantly changing
health and social care system, it is always going to be problematic
to judge the success or otherwise of a national reform such
as intermediate care. Nonetheless, three multi-site studies
have concluded that local intermediate care services are often
too small or too poorly organised to be effective [
14] (M. Godfrey,
personal communication; E. Regan, personal communication), and
an evaluation of a well-resourced, city-wide service reported
increased hospital use for a group of patients receiving intermediate
care [
15].
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Operational issues
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Despite the national targets, the optimum size for intermediate
care services was left to local health and social care communities
to resolve. With hindsight, a needs-based assessment for intermediate
care might have been an essential first step. Indeed, needs
assessment methods and results for whole system intermediate
care services have only recently emerged, and a surprising finding
has been the high percentage of 45% of inpatients in one healthcare
system who fulfilled a locally agreed criteria for the intermediate
care service [
16]. Services with the capacity to support proportions
of patients of this order imply a futility with what might be
generously termed embryonic intermediate care. In this situation,
some practical experience is achieved with inter-agency working,
but the services are small scale and relatively invisible within
the high-volume activity of mainstream older people’s
services. But service size alone is unlikely to be the sole
determinant of a successful intermediate care service. Common
sense suggests that a reasonable service capacity is required,
but increasing complexity and the wider engagement and integration
of intermediate care are additional important attributes evident
where intermediate care has matured from an embryonic to a larger
scale service [
14] (M. Godfrey, personal communication; E. Regan,
personal communication). Unfortunately, too many of the larger
scale services remain excessively fragmented—essentially
a collection of different intermediate care services each with
separate staff and separate entry criteria [
14] (M. Godfrey,
personal communication; E. Regan, personal communication). In
this criterion-driven form of intermediate care, patients can
be subjected to multiple assessments and many, particularly
those with cognitive impairment [
17], are excluded.
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Next steps
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The delivery of intermediate care in England needs strengthening.
We suggest that a bolder version of intermediate care is needed—one
that is more consistent with the needs of older people with
chronic conditions, including cognitive impairment. The current
perception of intermediate care as simply a new and discrete
tier of community services is to miss its full potential [
14].
It is useful to consider the underlying principles of intermediate
care: multi-agency working; comprehensive, shared assessments
and person-centred care based on an enabling (rehabilitation)
approach. There is no fundamental reason why these good practice
principles should be confined to intermediate care services.
Rather, the policy of intermediate care could be viewed as a
stepping stone, a practical mechanism, to introduce these important
concepts as acceptable and routine new ways of supporting older
people. In other words, intermediate care becomes an embedded
function of the care delivered by those staff engaged in supporting
older people in the community rather than as a service in its
own right. Thus, the person may sometimes be receiving intermediate
care according to our current understanding (e.g. care that
avoids unnecessary time in hospital), and they may at other
times be receiving ongoing care at home but delivered by the
same people. Essentially, most of the community staff will be
adopting a rehabilitation philosophy and incorporating the principles
of intermediate care into their daily practice. The key to this
approach is probably having a sufficiently large pool of well-trained
and well-supported generic rehabilitation/care support staff,
working as teams and under guidance from clinical managers,
to provide the day-to-day support for people and thus deliver
the continuity of care which service users, especially older
people, value highly [
18]. As with current intermediate care
practice, it would be crucial for arrangements to be in place
for quick access to medical assessment, for example from a general
practitioner or geriatrician.
The future pattern of community care for older people could be one in which well-resourced health and social care locality teams are jointly commissioned by the local planning partners. Such teams could bring together a full range of professions and skills, generalists and specialists, underpinned by many trained rehabilitative support workers able to offer continuity of care and able to respond flexibly and quickly to change in needs of the most vulnerable older people. In this way, we could achieve a step change in community care for older individuals with intermediate care as currently conceived becoming an historical steppingstone.
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Key points
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- Intermediate care is a new national community care service in England designed to bridge the gap between hospital and home.
- The intermediate care planning targets for England have been met, but it is unclear whether the strategic aims for the service have been achieved.
- There is evidence that many intermediate care services are too small, inadequately targeted or insufficiently integrated to achieve a whole system change to the care for older people.
- Wider dissemination of the intermediate care function could be achieved by incorporating its principles (multi-agency working; comprehensive assessment and enabling/rehabilitation approach) into service specifications for jointly commissioned local health and social services.
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Conflicts of interest
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J.Y. and J.S. have been protagonists of intermediate care on
the basis that community care for older people in England has
been neglected. Our views about the future of intermediate care
have arisen from the many visits we have made to intermediate
care services and teams in England during the last 3 years as
part of our work for the Department of Health and from educational
workshops we have contributed to. J.S. is an associate member
of the DH Health and Social Care Change Agent Team, and J.Y.
is a professional adviser to the DH. Both have contributed to
DH policy papers in this area. The views expressed here, however,
are privately held.
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Acknowledgements
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We are grateful to Dr Mary Godfrey and her colleagues and to
Ms Emma Regan and her colleagues for allowing us access to their
respective national studies of intermediate care.
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References
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- Department of Health. Better Health in Old Age. London: Department of Health, 2004.
- Department of Health. Shaping the Future NHS: Long-Term Planning for Hospital Services. London: Department of Health, 2000.
- Department of Health. The National Plan: a Plan for Investment, a Plan for Reform. London: Department of Health, 2000.
- Department of Health. National Service Framework for Older People. London: Department of Health, 2001.
- Grimley Evans J, Tallis R. A new beginning for care for elderly people? BMJ 2001; 322: 807–8.[Free Full Text]
- Ebrahim S. Proposals for intermediate care are reinventing workhouse wards. BMJ 2001; 323: 337–8.[Free Full Text]
- Pencheon D. Intermediate care. BMJ 2002; 324: 1347–8.[Free Full Text]
- Melis R, Olde Rikkert M, Parker S, van Eijken M. What is intermediate care? BMJ 2004; 329: 360–1.[Free Full Text]
- Health Service Circular 2001/01: LAC 2001/01.
- Martin GP, Peet SM, Hewitt GJ, Parker H. Diversity in intermediate care. Health Soc Care Community 2004; 12: 150–4.[CrossRef]
- Young J, Robinson M, Chell S, Burns E, Fear J, Sanderson D. Implementing intermediate care for older people. Br J Health Care Manage 2003; 9: 340–3.
- Wilson A, Parker H. Intermediate care and general practitioners: an uncertain relationship. Health Soc Care Community 2003; 11: 81–4.[Medline]
- Leaving Hospital – the price of delays. Commission for Social Care Inspection, October 2004.
- Herbert G, Lake G. Developing the Intermediate Tier: Sharing the Learning. Nuffield Institute for Health, University of Leeds, March 2004.
- Young J, Robinson M, Chell S et al. A whole system study of intermediate care services for older people. Age Ageing 2005; 34: 577–83.[Abstract/Free Full Text]
- Intermediate care strategy for Medway and Swale PCT. October 2003. http://www.changeagentteam.org.uk/_library/summaryMAy04.pdf/.
- Carpenter I, Kotiadis K, Mackenzie M. Intermediate Care: Organisation and Normalisation (ICON) Project. Centre for Health Service Studies, University of Kent, May 2003.
- Leaving Hospital – revisited. Commission for Social Care Inspection, October 2005.
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Introduction
Background