Good news on care

If successful, government policy on intermediate care will
pioneer joint working between health and social services and lead
to a seamless service, writes Matthew Taylor.

Recent reports of “blockages” of patients in Birmingham’s
hospitals, where a shortfall in the social services budget recently
left hundreds holed up in hospital beds, shows how far we have to
go in putting an adequate system of intermediate care in place and
how urgent that task now is.

The good news is that things are changing. The government’s
National Service Framework for Older People sets a timetable of
standards for care of older people to be met by 2004. For the first
time, following the establishment of the National Care Standards
Commission, we should see universal basic standards for care being
set and monitored across all institutions delivering care.

Perhaps the clearest indication of the government’s commitment
to improving the interface between health and social care is its
intermediate care policy. Under the NHS Plan £900 million was
designated by 2003-4 to develop intermediate care services. Initial
concerns from both the health and social care community about lack
of clarity over the nature and definition of intermediate care have
been partially eased by guidance produced by the Department of
Health in January. This establishes rehabilitation as the defining
feature of intermediate care. It sets out the range of services
that may be described, from rapid response teams providing care at
home to short-term rehabilitation in a residential care home.

Despite arguments from some critics that intermediate care is a
cynical attempt to relocate care into the community where services
and costs are cheaper and can be shifted onto the individual, the
concept overall has been welcomed.

But there is a problem. National policy directives are a crude
mechanism for bringing improvements that result in a genuinely
different experience for patients. There are several hurdles that
will have to be overcome for policies to translate into effective
local practice.

The first is funding. Out of the £900 million dedicated to
intermediate care, up to £405 million is earmarked for NHS
investment while the remainder will be allocated to social services
for provision of “a range of services that help users to live
independently”. Although it is appropriate that decisions about
funding allocation take place locally, new initiatives such as NHS
Direct, are often pump-primed so that they get off the ground in
the first few years. Without this type of dedicated funding there
is a danger that funding for intermediate care will simply be
absorbed by social services’ previous spending commitments.

The second hurdle will be staffing and training. Those who are
serious about providing a seamless service for intermediate care
have used an impressively thorough process of re-education and
retraining for staff that lets them develop a shared understanding
of the need for active rehabilitation and the nature of the service
they are providing. This means getting clinicians and nurses
involved in training from the beginning and acknowledging that the
NHS and social services must share the costs of training. For
managers, the ability to work effectively across both sectors will
be crucial and training opportunities for this must be
promoted.

Crucially, the vast majority of care staff working in
residential and nursing homes are employed in the independent
sector. The recent King’s Fund report Future Imperfect gave the
figure as 87 per cent in 1997. If private employers are not
involved and fully integrated into workforce development and
planning, prospects for service users will be bleak. One anecdote
is revealing: a private nursing home manager determined to create
an effective multi-disciplinary team in her nursing home, linked up
with a nearby university to design a teaching course specifically
for the purpose. But when she described her innovation at a
cross-sectoral working group for the development of intermediate
care services she was met with a combination of incomprehension and
indifference.

The third hurdle will be prioritising quality of care.
Currently, the only targets set for intermediate care are
numerical: 1,500 more intermediate care beds by 2002; 5,000 more
beds by 2004 – the list goes on. At the moment, many services
provided by intermediate care probably do not warrant the title.
Yet there is little to guard against token attempts to change
residential care into intermediate care. With health and social
care regulated in different ways and by different bodies, it
remains to be seen how standards will be protected. Evaluation must
focus on users’ experiences. Contracts with independent providers
must identify desired outcomes of care, rather than focusing only
on costs. Assessment of the success of intermediate care will come
from an analysis not just of the numbers treated but also of
re-admission rates to hospital and long-term care.

Many of the solutions to the challenge of providing effective
intermediate care will need to be met on a local level. In the
short term, while health and social care organisations struggle to
link more closely, results may not be dramatic. But, in time,
intermediate care can demonstrate that ideas such as user-focused
provision, joined-up policy making, and public private partnerships
can actually deliver real outcomes for some of our most vulnerable
citizens. At a time of growing scepticism about public sector
reform, it is just the kind of good news story the government
needs.

Matthew Taylor is director of the institute for public
policy research.