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.

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