The government is to invest £900m in intermediate care ser v ices des igned to keep o lder peop le out of hospital. Liverpool already has experience of using nursing home beds as alternatives to hospital care. The city has a large independent nursing home sector and, against a background of an ageing population and high hospital admission rates (see box, right), the health authority has been able to turn to this quarter for beds.

The HA first decided to use independent sector beds in 1997 for the provision of terminal care, followed in 1999 by the provision of intermediate care. The initial move was made following discussions with clinicians and local trust representatives, who agreed to provide NHS-funded care for terminally ill patients in registered nursing homes in the city. As a result of a tendering process, 15 homes were accredited - three have since withdrawn from the scheme.

As well as meeting the requirements of the Registered Homes Act 1984, the homes must provide:

single-room accommodation;

overnight accommodation for relatives or friends when necessary;

syringe drivers, pressure-relieving mattresses, hoists, suction and oxygen;

24-hour care planned by a nurse who has the relevant qualification (ENB 285/931) in palliative care;

commitment to training for all staff;

a quality management plan.

Access to the full range of primary care and specialist palliative care services is also provided.

A collaborative effort by the nursing homes registration unit, North Mersey Community trust, and Marie Curie Centre, Liverpool, helped ensure that the training needs of staff were identified and access to the relevant courses was offered.

A fast-track system of referral has been developed with assessments by Macmillan nurses, GPs and consultants.

Care is continually monitored by the community trust. All beds are bought on an ad hoc basis, and no more than five beds are bought in any home at one time. Work to improve the assessment and referral procedures led to a fall in the number of referrals during 1998-99 (see table below). The improvements resulted in a large drop in the length of stay, which fell from 70 days in 1997-98 to 38 days in 1998-99 and 33 days in 1999-00.

On the basis of local analysis of delayed discharges, which has shown that the average delay for older people is 25 days, it can be assumed that the use of nursing home beds saved 2,275 acute bed days in 1997-98,1,875 in 199899 and 2,650 in 1999-00. Eighty per cent of the patients died in the nursing homes,6 per cent returned home,2 per cent died in hospital and 12 per cent were still in the nursing home at the end of each financial year.

Winter and millennium planning The success of the terminal care project meant that Liverpool HA felt happy to use the independent sector to meet the winter and millennium pressures for intermediate care beds.

Although there is a considerable number of empty nursing home beds in the city at any one time, it was necessary to identify a configuration of beds that could be managed from a single point of access, ensuring robust admission procedures and consistency in standards of care. BUPA Care Homes, which provides 20 of the terminal care beds, identified 68 suitable beds in its four Liverpool homes. Timescales were tight as the decision to buy additional beds for use from the end of November 1999 to March 2000 was not made until October 1999.

A multi-agency group was responsible for developing the intermediate care scheme, and was able to use the terminal care bed project and other joint work to develop intermediate care across the city as a starting point. The group comprised representatives from the HA, North Mersey community trust, University Hospital Aintree, Royal Liverpool University Hospitals, Liverpool social services and BUPA Care Homes.

Patients could be referred from hospital or the community. They had to be Liverpool residents aged 65 or over and there had to be no anticipated acute changes in their medical condition during the following 24-hour period. Local GPs provided medical care on a contractual basis.

The scheme was linked to the emergency response team, which was a nurse-led service run by the community trust in partnership with Liverpool social services. The emergency team was able to refer, via community services such as the ambulance service, cases that did not need hospital admission. Referrals also came from hospital wards where patients needed an extended period of recovery, or where a care package could not be activated over the Christmas and millennium period. North Mersey community trust also assigned a tracker nurse, who was responsible for initiating the discharge-planning process immediately, to each of the four sites. A social worker and occupational therapist were also appointed to the scheme.

A total of 193 patients, who stayed for an average of 28 days each, were admitted from 29 November 1999 to 31 March 2000.A mid-term evaluation showed that at 31 January 2000,152 patients had been admitted. Ninety were admitted from hospital while the remaining 62 came via the emergency team or directly from home. Of the 152 admitted,80 were discharged home,31 were admitted to hospital, two were transferred to terminal care beds, two were sent for further rehabilitation, one went into residential care and three died. Of those admitted to hospital,45 per cent had been admitted from home.

A full evaluation of the scheme is being commissioned.

But in response to the national beds inquiry data, which confirmed that Liverpool residents were high users of non-elective beds, and that people aged 75 and over had a hospital admission rate 50 per cent higher than the national average, the HA has decided to continue to buy 30 beds from BUPA for intermediate care.

Joint working continues and a whole-systems approach to the intermediate care system in Liverpool is being developed that will incorporate a 'one-stop shop' referral to an intermediate care multidisciplinary team.

According to 1993 estimates, that almost one-fifth of the Liverpool population are of pensionable age. Its inhabitants fare badly in terms of ischaemic heart disease and stroke. Its health authority ranks 98 out of 100 in emergency admissions to hospital for people aged 75 and over, and Liverpool city council has estimated that 30 per cent of older people live in or on the margins of poverty.

In 1996, as a response to guidance issued by the Department of Health in circular HSG (95) 8, Liverpool HA produced its policy for continuing care, which included the needs of the terminally ill.

Liverpool had no continuing care beds following stringent reconfiguration of services and reinvestment in care in the community schemes.

At the same time, the Marie Curie Centre Liverpool had developed into a specialist palliative care unit with a significantly reduced length of stay. This meant that people who were not able to cope at home were likely to be admitted to an acute hospital bed as a last resort.

Key points A health authority which has been using beds in independent nursing homes as alternatives to hospital for older people since 1997 has found this a satisfactory model of care.

Initially the beds were used for terminal care only. Last winter the scheme was extended to provide intermediate care.

The scheme uses a maximum of five beds for terminal care in one nursing home at any one time.

The scheme is thought to have saved some 2,000 bed days each year.

The length of stay has been reduced and now stands at 33 days.