Pulled in all – directions

The NHS Plan is the catalyst for immense change in public
health. It has set up a series of national service frameworks,
which require many new roles to support the emerging ways of
working. But there is a difference between the new role of
intermediate care co-ordinator and the other roles of consultant
nurse, modern matron and patient advocacy and liaison
manager.

Intermediate care co-ordinators were not introduced as a result of
any national target. Instead they have been introduced locally in a
piecemeal manner by primary care trusts (PCTs).

Co-ordinators are now responsible for delivering intermediate care
targets within the framework for older people and the NHS Plan. So
co-ordinators need to be positioned where health and social care
services and primary and secondary care services meet. At national
and local level their role is high-profile and
ground-breaking.

In Birmingham, the foundation for co-ordinating intermediate care
was laid in April 2000. This was achieved through a series of
workshops, involving the strategic health authority, the specialist
community health trust, social services, voluntary organisations
and primary care groups, now PCTs. The experience and practice were
shared at a national workshop in July 2001, and resulted in
guidance.¹

Although intermediate care co-ordinators are an excellent idea in
principle, promoting cohesive working and translating policy into
practice has not been trouble-free. Birmingham found it difficult
to fill these posts, perhaps because they have a broad and evolving
remit. Also the roles could come under political pressure as the
government is anxious that they help deliver its election
promises.

Two elements have emerged as key to the role. One is at a strategic
level where the co-ordinator needs to have an overview of the
“what”, “where” and “why” of the services needed locally. The other
is at an operational level looking at the “how” of services, along
with day-to-day management to ensure a high quality and efficient
care programme for patients. Whether the post-holder performs all
these functions depends on the complexity and size of the
organisation.

Since their introduction, some PCTs have realised that
co-ordinators have a strong impetus to develop and deliver
intermediate care services. But, because this was not recognised
earlier, co-ordinators found themselves pulled in different
directions, and this resulted in several of the early post-holders
moving to other jobs.

Another feature to emerge was the differing professional background
required of post-holders. Some advertised posts specified a social
work or health care qualification, others asked for an NHS
management qualification. In some cases, local champions are being
purposefully selected for these posts because of their knowledge of
rehabilitation and local services.

Evidence across the country also suggests some people are already
carrying out intermediate care co-ordination functions as an
existing part of their role, while their title and pay may not
reflect this. And, with no recommended pay scale or monitoring, the
salaries offered for emerging posts have varied considerably and do
not always relate to the complexity of the job.

With such a wide-ranging role, it is inevitable that challenges
will emerge, focusing on professional, organisational and financial
boundaries. All issues are inextricably linked and must be
synchronised if intermediate care is to develop quickly. The manner
in which co-ordinators’ roles develop and their relationship to
other professionals unfolds in four phases.

• Operating within their own professional capacity.
• Exploring the role of other professionals.
• Engaging with other professionals.
• Expanding out of their “safe zone” to challenge professional
  culture and obtain the necessary changes.

What has emerged is fraught with the challenges faced by any
individual working in an inter-agency setting, especially as these
are the organisations that have often failed to work together
effectively in the past. Different professional or ideological
cultures, perspectives and responsibilities – as well as distinct
funding mechanisms, procedural mechanisms and issues of status and
legitimacy – make effective inter-agency working difficult. This is
apart from the need to work across geographical and organisational
boundaries.

The need to be seen to deliver by the government has led to tight
timescales for developing intermediate care work. Yet the time
needed to reach effective partnership working, let alone overcome
obvious barriers, places enormous pressures on the post-holders.
These pressures are compounded further because some posts are a
two-year contract. This can inhibit the development of skills as
the role evolves. And the valuable expertise developed by these
post-holders may be lost after the fixed-term contract
expires.

Support mechanisms started to take shape as more posts were filled.
A forum was set up, initially to draw in the many intermediate care
development ideas from Birmingham. This continued for the first 12
months and was replaced by a joint older people’s and intermediate
care forum, led by a PCT. Additional support has taken shape more
slowly, but the Royal College of Nursing (West Midlands region) now
hosts an intermediate care forum. Many of its members are
intermediate care co-ordinators. Support is largely from other
posts, such as modern matrons and consultant nurses, all recruited
to deliver the framework for older people.

Now, posts that emerged through separate local policies are
converging. Moreover, they are dovetailing to deliver specialist
intermediate and rehabilitative care. Finally, other subtle changes
have seen community assessment and rehabilitation teams being
renamed intermediate care teams or older people’s teams.

Effective inter-agency working requires a range of attributes,
which no one individual is likely to have. So, it is almost
inevitable that these post-holders will need considerable
investment in their training and leadership. They also need support
from their organisation in clarifying their role and keeping them
focused. Similarly, some external support, such as a formal
facilitated network, would allow ideas to be exchanged and some
consistency reached.

For parts of the country, however, there is a genuine need to gain
momentum in implementing these posts if they are to keep up with
the tide of changes.

Finally, the longevity of the intermediate care co-ordinator role
is paramount if they are to remain key figures, instrumental to the
implementation and co-ordination with social services providers of
intermediate care.

Liz Lees is a consultant nurse (acute medicine) at
Birmingham Heartlands & Solihull NHS Trust. Contact her
at
liz.lees@heartsol.wmids.nhs.uk

l References

¹ The King’s Fund, Intermediate Care Co-ordinators:
exploring the role, King’s Fund Institute, 2001