Half way there

The provision of intermediate care services is a central element
of the government’s strategy for older people – backed up by
unprecedented amounts of new money. It aims to promote independence
and avoid unnecessary admission into acute and long-term care. The
NHS Plan sets specific targets for increasing intermediate care
capacity in terms of more beds, increased levels of services and
new types of services.

Consequently agencies given the task of expanding intermediate care
are now developing a wide range of services – spanning the
continuum from home to hospital – to meet the specific needs of
their local population.

Very sheltered accommodation can play a vital part in this spectrum
of intermediate care services, a view that was formally recognised
in October 2001 by the signing of the Building Capacity and
Partnership in Care agreement between the NHS and private and
voluntary providers. In terms of intermediate care provision, the
agreement serves to encourage joint commissioning between health
authorities and social services and the establishment of
partnership agreements with, among others, the housing
sector.

However, central government enthusiasm for partnerships with
sheltered housing providers is not necessarily equalled by health
authorities and social services departments.

A postal survey of 100 primary care trusts by the Hanover Housing
Association revealed that the majority of respondents cited
residential and nursing home care as the main area in which they
were expanding their provision of intermediate care beds. Many
referred to spot purchases, increasing care home fee levels and
new-build projects in order to increase capacity.

So it appears that some agencies responsible for expanding the
provision of intermediate care services are more likely to look
towards care homes, because this is deemed to be a more
“straightforward” option; buying additional care home spaces is
considered less complicated than incorporating intermediate care
flats on very sheltered housing schemes. Consequently, the option
of very sheltered housing has to some extent been cut from the
intermediate care menu.

But the ability of the care home sector to provide intermediate
care beds is open to question. The rate of care home closures has
continued to increase: from the 1996 peak of 575,600, some 64,300
places had been lost by April this year.¹ And evidence
suggests that the lack of capacity in the care home sector accounts
for one out of three delayed discharges from acute hospital
sites.²

More importantly, are care home settings – which are often designed
for long-term care – suitable for short-term intermediate care?
Equally, while admission to a care home is appropriate for many
people, it can be inappropriate for the significant number of older
people who, with the help of effective intermediate care services,
can be enabled to return home following hospital treatment.

So, many older people are being inappropriately and prematurely
placed into care homes. This then limits the places available for
those people who need the heavily supported environment that
residential and nursing homes offer.

On the other hand, the provision of specially designed
self-contained flats within very sheltered housing is arguably more
conducive to maximising older people’s independence and their
subsequent return home following their hospital treatment. For the
main focus of most very sheltered housing schemes is to promote
independence, in that every element is designed to enhance the
home-from-home feeling.

The very sheltered housing environment provides support for its
residents through the provision of an estate manager on site, a
social alarm call service and the provision of a midday meal for
all residents. Almost all very sheltered housing schemes are
designed with features such as full wheelchair access, level access
showers, and height adjustable units.

Most importantly, 24-hour care is provided in most very sheltered
schemes through relevant social services departments. Housing
providers who have established partnerships with care providers can
also provide the flexibility of personnel that may be needed to
cover staff shortages or provide all levels of care staff
permanently.

Current indications suggest that the operational costs of providing
intermediate care in very sheltered housing schemes are lower than
in acute hospital wards and nursing homes and are comparable with
those of residential care.

There is little doubt that health authorities and social services
departments appreciate the contribution that very sheltered housing
can make in the field of intermediate care provision. However,
there is still a lack of awareness of how intermediate care will
work in the very sheltered setting, and consequently it remains a
daunting prospect for many organisations.

At the same time sheltered housing providers must remain flexible
in their approach so that the potential of very sheltered
accommodation in the field of intermediate care can be
realised.

Due to local differences there cannot be a universal housing model.
Sheltered housing providers need to be aware of how local systems
work and develop ways in which very sheltered housing can be
integrated into wider intermediate care systems. There is no
blueprint in terms of provision of intermediate care in very
sheltered housing schemes because everyone has a different starting
point. Therefore the detail of provision through these schemes must
be determined by the local needs and resources, with new
developments linked together to make a strategic coherent
whole.

For example, flats can be adapted in existing schemes and
additional facilities incorporated. Alternatively, new developments
can include provision of a small number of flats and facilities
dedicated to providing intermediate care. Even the option of
building large-scale, purpose-built accommodation dedicated solely
to the provision of intermediate care cannot be ruled out in
certain circumstances. Put simply, there is no “one size fits all”
approach, and models of housing must be flexible enough to meet the
needs of local commissioning agencies by fitting in with other
services that are already in place.

Government guidance states that intermediate care, as a health
provision, has to be free to the service user, and this prevents
sheltered housing providers issuing tenancies to individual people.
Furthermore, because intermediate care is time-limited, and
residents will only be in the flat for a maximum of six weeks
(often as little as two weeks), the issue of tenancies also becomes
an impractical option.

One possible alternative to issuing tenancies to individuals is to
provide the properties through a lease or management arrangement
with health authorities and social services departments: many
sheltered housing providers are still in the process of
establishing how these contracts will work. For example, if the
flats are leased, the issue of whether the scheme needs to be
registered must be tackled.

Another problem is posed by the fact that intermediate care is a
health provision, which is currently outside the funding criteria
of the Housing Corporation, the main grant body for the majority of
social housing providers. Consequently, providing the flats on a
lease could result in repayment of any social housing grant used to
build the scheme. Not only will this deter housing providers from
getting involved with intermediate care because of the financial
impracticalities, it could also increase the rents beyond the
acceptable level for intermediate care requirements.

The capital funding surrounding the provision of intermediate care
on very sheltered schemes seems uncertain. However, the Office of
the Deputy Prime Minister and the Housing Corporation are currently
working to solve the problems, together with the Department of
Health. Similarly, it is up to social services and health
authorities to work in partnership with the housing sector to find
solutions to what must be regarded as a vital element in the
spectrum of intermediate care.

John Gatward is chief executive of Hanover Housing
Association.

² P Burstow MP, No Room at the Inn; the Causes of
Gridlock: Leaving the Old in Limbo, Liberal Democrat Party,
October 2001