Can things only get better?

Most agree that intermediate care is a good thing and that it
will greatly improve the lives of older people. What is exercising
many, however, is how the services will be co-ordinated, delivered
and financed. Frances Rickford reports.

You’re 90, live alone and have a fall. Your hip cracks, you’re
taken to hospital. While you’re there you get a chest infection,
then pneumonia. The pneumonia is brought under control but you are
still weak, and the broken hip has exacerbated mobility problems
caused by arthritis. Acute beds are under pressure, so you are
assessed and found a bed in a residential home. You never go home
again.

Intermediate care should rewrite this story. Instead of being
taken to hospital, you could perhaps expect to receive an intensive
“hospital at home” service, followed by a multi-disciplinary
planned rehabilitation programme. If you needed to be admitted to
an acute bed, you could be discharged to a residential intermediate
care facility, perhaps based in a nursing home, for a six-week
programme of physiotherapy, occupational therapy, medical and
nursing care and social work support. Either way, at least in
theory, you end up back in your own home instead of living out your
days in an institution.

If it works, intermediate care is not only a better option for
older people. It could also save the NHS and social services money,
and so increase capacity. But the process of getting from here to
there is daunting for the organisations involved.

Government guidance sets out strict criteria for what counts as
intermediate care. It must be provided only to avoid “unnecessarily
prolonged” hospital stays, inappropriate admission to acute
in-patient care, or long-term residential care, and must be based
on a comprehensive cross-professional assessment, leading to a
structured individual care plan.

Jan Stevenson, rehabilitation programme manager at the King’s
Fund, outlines some of the problems that health and social care
agencies locally are confronted with. The winter pressures money –
the extra cash offered to health and social care over the past four
years for joint initiatives to relieve pressure on acute hospital
beds – has led to a wide range of very successful initiatives. But,
according to Stevenson the job of integrating them into mainstream
services is huge.

“Wherever I go there is a consistent message about how difficult
it is to deal with the fragmentation of services. No one can
identify where all the new money is in the system and local
managers who have been innovative are now being told their
particular services have to change because so much more has got to
be done now.

“Older people are supposed to get a joint multi-disciplinary
assessment, but the different professionals often can’t even get
their own separate assessments into the same folder. It’s not so
much a problem between health and social care professionals as
between all the different tribes within the health service.”

Stevenson reports that another major obstacle to implementation
is staff recruitment.

“People have really good schemes waiting to get under way, but
can’t recruit the therapists. And if you can’t put someone in the
job, what can you do?”

There are also other thorny personnel issues to be faced, such
as training care assistants to deputise for professional staff, and
persuading the professionals to let someone else do parts of their
job. People are also having to change workplaces as well as the way
they work.

Glenys Jones, chairperson of the Association of Directors of
Social Services’ older people’s committee, is less gloomy about
progress towards implementing intermediate care than Stevenson, but
emphasises the importance of securing robust agreements now on what
will and won’t be paid for from the intermediate care pot.

“It is a new service and we expect it to develop over a number
of years, but my impression is that people are getting on with it.
The main job at the moment is to get together with health on how
much money is to be ring-fenced and pooled, and exactly what is in
the intermediate care framework. For example, the guidance is clear
that it is not supposed to substitute for hospital rehabilitation
services. So if you have had a stroke, you would get rehabilitation
as part of your stroke package.”

Social services have not always been happy with the outcome of
the horse trading, according to a survey by the ADSS. Directors
report that health authorities have not spent all the money given
by the government for intermediate care on intermediate care
services, and have not always involved social services in decisions
about how to spend the money.

The survey also shows that pressure on adult care budgets is
increasing – largely because of increased demand and rising costs
of residential care places. The extra money allocated to local
authorities for intermediate care services was not ring-fenced and
some of it is probably being absorbed into general adult care.

Controversially, the government has specified that intermediate
care should normally not last more than six weeks. Age Concern’s
community care policy officer Stephen Lowe is concerned that this
could lead to people leaving hospital, getting their six weeks’
intermediate care, then having to be readmitted to hospital.

Age Concern is also worried that there will still be confusion
for service users about the boundaries between free and charged-for
services, and wants more transparency as well as a procedure for
appeal or review when people are unhappy about the package they are
offered. “We would also like better monitoring of how the system is
working in practice,” says Lowe.

Jan Stevenson believes that the size of the job means
implementing intermediate care is going to take longer than
envisaged, and needs to be paced more slowly if it is to be done
well. But the key to success will be local leadership.

“People are trying very hard and want to make it happen. But
this is a big change agenda and it needs a lot of managing. The
National Service Framework for Older People says there will be a
lead champion, but they haven’t been identified yet. What you need
is for the senior people to be empowering and enabling and
supportive of change, and motivating people. If it’s not the
priority it is not going to happen. You can’t do this at middle
management level.” CC

Evidence is key to promise of intermediate
care

If intermediate care is to fulfil its promises, more reliable
research evidence is needed about what interventions work for which
older people, argues Finbarr Martin.

Intermediate care has come up fast as a front runner to improve
matters for frail older people. It’s tipped strongly from the
centre and has attracted local champions. But has it delivered? And
can it do what its backers promise when it becomes mainstream, the
gloss has faded and the charismatic leaders have been promoted
away? In my view, it won’t succeed without a leap forward in the
sophistication of analysis and discussion between health and social
care partners.

The central problem might not be about money. Funding is crucial
of course but we’ve already had most of the new money that was
promised. Local agreement may be easy to achieve when there’s
ring-fenced new money dangling, especially in a quick and pragmatic
process like winter pressures capacity planning. But it turns out
differently when it comes to moving around scarce funds already in
the system.

By its very nature, intermediate care needs the involvement of
people with a range of skills including clinical diagnosis,
multi-faceted assessment and social care. At present, both
nationally and locally, the widely differing beliefs among
“partners” continue to undermine the essential collaboration.

Geriatricians have set out some principles from a clinical
standpoint¹ but many remain sceptical and feel excluded.
We could do better by sharing concerns and developing a more
critical approach.

As the national NHS Plan states, “…patients must receive the
right care at the right time in the right place.” A plethora of
Department of Health publications,² authoritative
reports and research studies have suggested that a significant
number of older people are in hospital unnecessarily, some simply
waiting, others receiving care, usually rehabilitation, that
perhaps could happen elsewhere.

On reflection, this seems surprising in view of the dramatic
reduction in NHS bed stock from 480,000 to 190,000 between 1948 and
1998. Geriatric beds have fallen from 56,000 to 30,000 since 1978
and the time spent in hospital has also reduced by two thirds over
this period. The pressure on time and resources meant people were
unable to recover adequately in hospital and these pressures
resulted in many moving into long-term care
prematurely.⁶

An appreciation of this, and the enormous costs of care home
provision which had persisted despite the provisions of the NHSand
Community Care Act 1990, prompted government guidance to develop
better health and social care integration to promote
rehabilitation.

Although neither new in name nor general purpose, intermediate
care was launched at this time. Recent figures, however, show
admissions have continued to rise by more than 3 per cent per year.
Some increase reflects demographic changes but the rest is less
well understood. Despite this uncertainty, limiting this trend to 2
per cent per year is another national plan target which
intermediate care is meant to deliver.

The new flexibilities in the Health Act 1999 and the growing
experience of partnership boards should help, but for sustainable
and effective intermediate care there is no skipping over the real
dialogue about exactly what are we trying to do, for whom, when,
and with what skills.

The national guidance emphasises the focus on short-term
multidisciplinary rehabilitation, aimed at hard outcomes such as
reducing hospital stays and use of care homes. Do we agree how to
do this? Health and social care have different traditions and
languages about knowledge. Partnership grant funds have been
obtained on good policy intentions, and largely monitored on
process. When it comes to partners redirecting funds more certainty
will be needed.

The randomised controlled trial is well established as the best
method to evaluate the effectiveness of well-defined health care
interventions, and is able to distinguish the resultant outcomes
from those that would happen anyway or by chance. The difficulty
with complex “treatments”, such as rehabilitation or intermediate
care, is that the ingredients are more difficult to define than
those of a drug cocktail, so we do not really know whether the
effect of one team will be the same as another, even when the teams
share the same name and the same purpose.

Furthermore, the users who benefited from these “treatments”
need to be carefully defined so that we know who should get the
same treatment elsewhere. Evaluation has shown that even teams that
share operational policies take on distinctive clients and have
gross variation in practice and contact time. So the language of
assessment will need to capture the key user characteristics that
identify those individuals for whom there is evidence of
benefit.

The published literature rarely does this in sufficient detail.
The grey literature of local evaluations is no better and is
frequently subjective. “At risk, difficulty coping, frail” have
intuitive meaning but do not have constant meanings across
different teams or professions. On the other hand, reducing
individuals to numbers such as can be done with cognitive and
functional assessments does not capture the particular feature or
combination of features which might result in one person doing well
with a particular scheme and the other person not. These qualities
are difficult to define but nonetheless real.

We need to get round this. Otherwise the right care, care that
works, cannot be consistently applied to the most suitable people.
For example, evidence is reasonably strong that community-based
supported discharge teams can assist successful resettlement at
home and reduce subsequent entry to care homes for selected
people.^4,5 It may be true for others but we don’t know.
Those with more complex needs might do better with specialist
teams. For stroke, this is almost certainly the case. Those at
lesser risk might obtain no additional benefit. So, although the
extra resources are being wasted, the good outcome is likely to be
regarded locally as success.

Will performance management help? It could do if we use it to
benchmark against known measures of user suitability and expected
outcomes and also to monitor over time for drift in user
characteristics, resource use and outcomes. This won’t happen if
our energies are consumed with the current type of reporting. The
pressure in regional offices to achieve targets puts the emphasis
on numbers using various schemes, defined by purpose. Whether they
achieve their purpose is less clear. For example, timely admission
to a care home rehabilitation wing to avoid hospital admission
sounds entirely plausible, in general terms. It has its own line in
the quarterly health authority reports (SaFF). Remarkably there is
no peer-reviewed published evidence that such an approach either
prevents subsequent hospital admission or is an effective or
efficient alternative to hospital or domiciliary options. This is
not to say that such schemes cannot be effective. It does mean
though that selection of suitable users (ie those who will benefit)
or suitable staff attributes is still problematic. So while we feed
upwards wishful thinking, we might better use the limited resources
to provide clinically helpful information to assist service
evolution.

This is a difficult area and local enthusiasm has to start
somewhere. This is not a call for inertia while “the experts” do
the trials. But we need to acknowledge that common sense
presumptions about effective services for older people are
generally ageist. We don’t base care of other people on such weak
foundations.

¹ British Geriatrics Society.
Compendium- www.bgs.org.uk/compendium/compend.htm

² DoH, Shaping the Future NHS: Long Term
Planning for Hospitals and Related Services, DoH,
2000

³ NHS Executive, Emergency Services
Action Team 1998 Report, DoH, 1998.

⁴ G Parker, P Bhakta, C Lovett, S Paisly, S
Parker, R Baker et al, “Best place to care for older people after
acute and during subacute illness: systematic review”, Journal
of Health Services Research and Policy 2000;5(3)
176-189.

⁵ FC Martin, A Oyewole, AA Moloney,
“Randomised controlled trial of a high support hospital discharge
team for elderly people”, Age Ageing 1994; 23:
226-234.

Finbarr Martin is consultant physician and geriatrician,
Guy’s and St Thomas’ Hospitals, London, and former chairperson of
the British Geriatric Society’s policy committee.