Singing from the same hymn sheet

New guidance for intermediate care should provide the same
framework for both health and social services. But perfect harmony
will need hard work. Jan Stevenson explains why.

Long-awaited guidance¹ from the Department of Health
on the development of intermediate care landed on NHS and local
authority chief executives’ desks in January. Unusually, there was
no accompanying publicity or fanfare for what could turn out to be
a very important document. The guidance was promised in the NHS
Plan² in July last year and is to be followed soon by
the much-delayed National Service Framework for Older People’s
Services, and new guidance on comprehensive assessment.

Most people agree that there is a yawning gap in the range of
health and social care services for older people. An expansion in
intermediate care services will fill that gap, promoting
independence among groups of people who have received long-term
care prematurely or remained inappropriately in hospital when their
care needs could best be met at home or closer to home.³
That expansion has already begun with a number of stand-alone
initiatives designed to prevent winter pressures from building up
in hospitals this year.

But, listening to managers in health and social care, it becomes
very apparent that there is a lack of consensus about exactly what
we mean by intermediate care, who can benefit from it and how best
to organise services to deliver it most effectively. Most people
describe it in terms of the settings where care is offered,
typically step-up or step-down beds in hospitals, nursing or
residential care homes, or in terms of teams of people working
together such as rapid response or community rehabilitation
teams.

The guidance is to be welcomed therefore, as it gives a standard
definition of intermediate care “to ensure a clear and consistent
approach to developing, monitoring and benchmarking services across
the country”. Five criteria are listed, all of which must be met
(see below). Particularly welcome is the emphasis on
cross-professional working; assessment; individual care planning
involving patients, and users and carers; and active
rehabilitation.

By time-limiting care, a clear message is given that
intermediate care is not about warehousing or dumping older people
nor is it about marginalising them from mainstream services.
Extensions to periods of intermediate care are possible, if the
need is justified on reassessment. There is a clear expectation
that providing active therapeutic support will act as a bridge
between home and hospital enabling people to regain their
independence.

Interestingly, many existing “intermediate care services” do not
fulfil all five tightly-defined criteria. In particular, to achieve
the requirement for a single assessment framework, single
professional records and shared protocols, which are widely
accepted as good practice, will need to be developed within
existing teams and across agencies.

The development of intermediate care services has to be seen in
the context of the whole system of health and social care. It will
be no good expanding intermediate care services if they are not
integrated with a wider range of services on the care continuum.
While acknowledging the need for a whole systems approach, the
guidance concentrates on the future planning and development of
short and time-limited interventions. This may lead to continued
fragmentation of rehabilitation care for older people. New services
may stand alone unless agreements and protocols are in place with
the acute and community services to transfer people who will
benefit from the new service into and out of intermediate care.

To bring about the required fundamental shift to promoting
independence instead of encouraging dependence means that everyone
involved in supporting older people needs to embrace this enabling
philosophy. This means changing the culture of care services rather
than just creating a new set of services.

For example, generic community health and social care services,
to which people are referred following an episode of intermediate
care, must be geared up to adopt a rehabilitation approach to
on-going care. We have seen people become more dependent where the
service culture is “do to or for” rather than “enable”.

Equally important is beginning the rehabilitation process as
soon as possible in an acute episode of care, which means that
hospital teams need to plan and begin therapeutic care alongside
diagnosis and treatment. In many areas there will need to be
significant investment in developing these services in related
parts of the care system. It may be difficult to prioritise such
developments, given the size of the overall change agenda in the
NHS.

New NHS funds announced in the NHS Plan and clarified in this
new guidance (£405million by 2003-4) are specifically
earmarked for the development of intermediate care. There are
clearly dangers that the money may be diverted for other purposes
in the NHS.

Furthermore, a “substantial amount”⁴ of the total
£900 million for intermediate care service developments
announced in the NHS Plan is already included in the personal
social services standard spending assessment provided to local
authorities. This money cannot be earmarked, though it is said to
be for “a range of services, which link to intermediate care”.

There is a danger that financial pressures in local authorities
may lead to this new money being diverted to other priorities,
since the deployment of resources through the standard spending
assessment remains a decision for councils to make in the light of
local circumstances.

Developing intermediate care is the joint responsibility of
health and social care communities and will be seen as a key test
of how well these partnerships are working. There is an expectation
that the use of new powers under the Health Act 1999 will be the
norm in arranging intermediate care. These allow authorities to
pool their budgets, to create lead commissioners and to merge
services under one provider. Pooled budgets will require new levels
of partnership. It may take some time for local agreements to be
reached and for operational systems to be set up.

To encourage take-up of services and simplify arrangements, the
expectation is that any intermediate care will be free at the point
of use. This will mean that components of the service that would in
other circumstances be charged for, such as residential and nursing
home care and home care, will be free. It is to be hoped that any
loss of income and the need to distinguish chargeable and
non-chargeable care, will not be a deterrent to social services
participation.

How much should be invested in buildings and beds and how much
in home-based support? Service commissioners have found it
difficult to decide what balance of intermediate care in different
services and service settings might be needed for any given
population. Knowing that they will be monitored against targets for
beds or places, authorities may be tempted to invest heavily in
provision within residential and nursing homes and community
hospitals.

They will certainly have an incentive to do so. Services linked
to beds and buildings (particularly if new build private finance
initiative options are chosen) can tie large amounts of money into
this configuration of care services for many years. We then risk
fitting patients to services rather than providing flexible care
tailored to individual assessed needs.

It will be difficult to monitor change over time on some
targets, when there is no validated record of the baseline from
which agencies are starting. There may be perverse incentives to
re-badge some existing services to portray a low starting point.
Conversely, agencies with relatively high current provision may
find themselves penalised if they do not increase bed numbers or
places.

Does the system have the capacity to implement these major
changes in ways of planning, involving users, working (both
organisational and professional), monitoring and accountability. It
will be some time before we begin to get answers to these questions
enabling us to judge if the NHS Plan was right to claim that
“intermediate care will end widespread bed-blocking by 2004”.

This is a real window of opportunity to make major improvements
to the care and support of older people giving them a better chance
to regain control over their lives and to live independently at
home after illness or injury. This is what older people themselves
say they want. Their views have been taken account of in government
policy, backed now by substantial increases in funding to develop
new types of support and care. Recognising some of the challenges
to be faced in implementing these changes should help commissioners
and providers to come up with innovative solutions that deliver
better care and positive outcomes for older people.

¹ Department of Health, Intermediate
Care, HSC 2001/01: LAC (2001)1 , DoH, 2001

² Department of Health, The NHS Plan. A
plan for Investment; a Plan for Reform, Cm 4818-I, The
Stationery Office, July 2000

³ J Robinson et al, “The NHS Plan: What Does
it Mean for Community Care?”, Managing Community Care,
8:6, 2000

⁴ Department of Health, The Health Act,
1999, Stationery Office, 1999

Jan Stevenson is programme manager at the King’s
Fund

Standard definition of intermediate care

• Services that meet all the criteria below:
• are targeted at people who would otherwise face unnecessarily
  prolonged hospital stays, or inappropriate admission to acute
  in-patient care, long term residential care, or continuing NHS
  in-patient care;
• are provided on the basis of a comprehensive assessment,
  resulting in a structured individual care plan that involves active
  therapy, treatment, or opportunity for recovery;
• are planned to maximise independence and typically to enable
  patients and users to return home;
• are time-limited, normally no longer than six weeks and
  frequently as little as 1-2 weeks or less; and
• involve cross-professional working, with a single assessment
  framework, single professional records and shared protocol.

Source: Department of Health, Intermediate Care,
HSC 2001/01, LAC (2001)1, 19 January 2001