Although many hospital patients would be better off at home, intermediate care is regarded with scepticism in many quarters. A shift in attitudes is called for, according to Jacqueline Mallender and Andrew Richman

Both evidence and anecdote show that many people are being cared for in hospital who could be supported at home.

More worryingly, for many of these people the care they receive does not adequately meet their needs, potentially resulting in extended periods of illness and dependence rather than recovery, rehabilitation, good health and independence.

The national beds inquiry presented evidence from a study undertaken by York University which concluded that about 20 per cent of the days older people spent in hospital would probably be deemed inappropriate if alternative facilities were in place.

4So how is this problem to be solved? The inquiry put forward three scenarios for the future of the health service, one of which sees the development of intermediate care services 'closer to home'. These are intended to act as a bridge between hospital and home and between acute and primary health and social care services. But it is less clear how these services can be best developed and whether the current health and social care system is empowered to implement such major change over the coming years.

Building intermediate care services will require significant investment and, inevitably, a rebalancing of resources away from acute hospitals. But despite many years of successive governments' attempts to develop primary and community health services, policies and debates on the health service still centre on the concept of hospital - and indeed acute hospital - provision. Change along the lines envisaged by the 'closer to home' scenario will require nothing short of a revolution in the thinking of many health professionals and indeed the general public.

A fundamental obstacle to change is the paucity of high-quality evidence demonstrating how intermediate care services can deliver effective outcomes in a cost-effective manner.

5Without evidence of good practice it is very hard to convince sceptical practitioners that scarce resources should be channelled into the development of these services.

But it is this local focus that provides the very opportunity to develop the much-needed evidence. An essential characteristic of intermediate care is that the definition and scope of the service varies according to local needs and circumstance. In practice, most areas have some services up and running which have been developed as part of short-term winter pressures initiatives, or other related non-mainstream funding routes. Most of those involved will be well aware of the elements of these schemes that work well and the gaps which still exist. A good place to start, therefore, is a comprehensive assessment of local needs and resources, combined with a comprehensive evaluation of the role of existing rehabilitation and intermediate care services.

The benefit of locally focused evaluations is that local clinicians and other health and social care professionals must be involved. Focused attention on the problems and issues associated with delivering care to this group of patients can open people's eyes to the huge opportunities for improving and developing services in a different way.

Panel reviews of cohorts of patients can result in a much better understanding of systemic failures and how these can be addressed by the different and essential contributions of all the different disciplines.

Unfortunately, even locally generated evaluations and proof of effectiveness may not be sufficient to challenge long-established power bases that are resistant to the potential movement of resources from the hospital sector into the community. Many health professionals, having been trained to see the hospital as the focus of healthcare provision, see working in the community as an unattractive alternative.

The solution lies with the leadership of the new primary care groups and primary care trusts and the effectiveness of the joint partnership arrangements that exist. Clear, effective, needs-led commissioning is essential if the powerful vested interests mentioned above are to be challenged. Strong leadership is going to be shifted from one sector to another and innovative whole systems are to be generated.

REFERENCES

1 The Coming of Age. Audit Commission, 1997.

2 Clinical Standards Advisory Group. Community Health Care for Elderly People. Audit Commission, 1998.

3 Fit for the Future: the prevention of dependency in later life. Report of the continuing care conference, prevention of dependency in later life study group, chaired by Elizabeth Mills. Research into Ageing, 1998.

4 Shaping the Future NHS: long-term planning for hospitals and related services. National Beds Enquiry. Department of Health, 1999.

5 Government may press on with closer-to-home beds strategy. HSJ, 110 (5706): 6.