Intermediate care has been redefined and given a new emphasis - as well as new money. But the model being introduced has had little evaluation and may produce no added benefits to patients, says Claire Laurent

Anyone who thinks intermediate care is a dumping ground for older people blocking acute beds had better think again. Tight criteria from the government, issued in January this year, emphasise active therapy, rehabilitation over a time limit of up to six weeks, maximising independence and involving cross-professional working.

1The government circular states that intermediate care services should be: targeted at people who would otherwise face prolonged hospital stays, or inappropriate admissions to hospital or residential care; provided on the basis of comprehensive assessment; time-limited, normally no more than six weeks.

Services must meet all these criteria to meet the definition of intermediate care, the circular says.

In short, intermediate care is just that: care That is needed between the acute ward and home which promotes independence.

'That is where the clarity is very important, ' says Jan Stevenson, rehabilitation project officer at the King's Fund. 'There has been and still is a huge gap between health and social services care.

Intermediate care is clearly defined to fill that gap. '

What is also clear is that intermediate care has to be part of the system and can't function if the rest is failing. National director for older people's services Professor Ian Philp says: 'It will be time-limited and will therefore have to integrate within the mainstream service. '

He adds: 'Intermediate care is something that all relevant stakeholders will engage in. It should not be a ghetto service and is not to be something That is dropped on one profession - GPs or people working in cottage hospitals or the private sector - or on families. '

Ms Stevenson says: 'At least There is now a definition, which is very helpful because up until now people have been confused about what intermediate care is. ' But she warns: 'Very few of the current services that are now called intermediate care meet the criteria. Up until now It is been possible to label something as intermediate care if it didn't have active care. . . now people must be focused on rehabilitation. ' The real sticking points, according to Ms Stevenson, and for which there will be further guidance, are the requirements for a single professional framework and the single professional assessment.

But Chantal Smith, planning manager for Tameside and Glossop Community and Priority Services trust, is delighted with the criteria: 'The objectives we are pursuing in our community rehabilitation team and resettlement team are right. We meet those criteria, which is amazingly supportive to know. '

Ms Smith is very clear that intermediate care is not an 'add-on' service. 'It needs to be developed within the whole system because otherwise what you get are failures in other parts of the system. These can affect the impact intermediate care can make.

'In the wards there are any number of problems that can impact on whether people make use of intermediate care services. They include things as basic as the timing of ward rounds, who has the authority to discharge, how well the discharge is managed. Because of staff shortages, people are not going round identifying those who need intermediate care - they're too busy. Major cultural changes have to be made in hospital and social services because you can rehabilitate someone and transfer them to home care, but if you haven't got a service That is about promoting independence, you can undo something fairly quickly. '

The£900m promised by 2003-04 for intermediate care in the NHS plan has certainly thrown it centre stage. Of that money, around£255m is to be earmarked specifically for the NHS. However, Jan Stevenson says: 'I think it was a bit of a surprise to many people that a large amount of it was already in social services' spending assessment. The problem is that you can't earmark that money.

Although it is said to be for intermediate care, social services can make individual decisions about how they spend that SSA. '

A sum of£150m is to be made available recurrently from 2000-01. This winter, says Ms Stevenson, the money was used by many agencies 'to keep people out of hospital. A lot has also been spent on setting up new schemes and expanding what's there. And clearly there has not been the huge problem that there was last winter, ' she says. While the money has been welcomed in all areas, many expressed the view that at the frontline it still didn't feel as if intermediate care 'was awash with money'.

Others voiced their concerns about the national shortage of therapists and the difficulty of recruiting when projects were short-term. The issue of charging for social care but not for healthcare continues to be a problem, not entirely solved by pooled budgets. 'It is a bit of a nonsense to have something in parallel That is charged for and not charged for, ' says Gill Greenwood, Sheffield social services resource centre project manager (see box overleaf ).

Developing a 'virtual neuro-rehabilitation team' is the next item on the agenda in Tameside and Glossop's impressive array of intermediate care projects. 'It is to make sure we can give that group of people co-ordinated care, ' says Chantal Smith. 'In the past, these people have had a service but It is scattered all over the country. The virtual team is pulling those people together. '

There are three well-established intermediate care schemes in place in Tameside and Glossop: the rapid-response team, a community rehabilitation team and a resettlement unit.

Opened in December 2000, the resettlement unit has five beds but will have 20 when building work is completed. 'It offers intensive rehabilitation in a safe environment, ' says Ms Smith. 'It uses the same documentation and the same systems as the community rehabilitation team, so the next step for us is to integrate both teams. '

The first intermediate care service developed in Tameside and Glossop was a rapidresponse team. Similar services operate in many other areas of the country, sometimes under different names but usually with the same intention: keeping older people who are in a crisis out of hospital by caring for them at home.

'It is a bridging service for one or two days.

You get a patient in crisis, the GP sees them and refers them to the rapid-response team. We put in night sitting or what's needed and that gives us time to get a care package together. So the person stays in the community, ' explains Ms Smith.

A community rehabilitation team developed some two years later when a readmission audit identified the really heavy users of health services.

They were summarised as those with chronic obstructive pulmonary disease, 'fallers' and three orthopaedic conditions: replacement hips and knees and fractured neck of femur.

'The service provides six weeks' intensive rehabilitation in the community, generally in people's homes, ' says Ms Smith. Some are then offered case management so that they can call out a team member who will support them in a crisis and arrange admission to hospital if necessary. 'Chronic obstructive pulmonary disease responds very well to educative approaches, ' says Ms Smith. If people are told how to manage the situation they panic less and their quality of life improves and they have fewer hospital admissions. '

An important aspect of intermediate care is the development of multidisciplinary teams. In Portsmouth, as in other areas, health and social services staff work together to deliver patient care.

'We are working purely in the community, getting multidisciplinary rehabilitation to people over the age of 65 in their own home or residential home, ' says Jackie Lelks, team manager of Portsmouth city community rehabilitation team. The team provides rapid-response care, but also longer rehabilitation work over a six to eight-week period.

'We are also working with people who have been in long-term residential care, to help a return home if that is their aim, ' says Ms Lelks. 'We recently returned someone home who had been in care for 10 years. '

What she has noticed, and this has been echoed by others in the field, is the greater frailty of the older people now receiving intermediate care. She says: 'People who are coming out of hospital are frailer and more complex than they were. Whether That is because people know the team is there, I do not know. '

She says this increases the time commitment - not so much an extension of the rehabilitation time but an increase in its intensiveness, which has a knock-on effect for other referrals.

At Community Health Sheffield trust, Maureen Ibbotson is rehabilitation nurse co-ordinator for community health and runs an intermediate care project that was established in 1996. 'We subcontract with a nursing home to provide 20 beds for rehabilitation for people over 65. It is a three-way partnership between Community Health Sheffield trust, the nursing home and the Royal Hallamshire acute trust. I think the patients are older and very much more dependent than they were, ' she says.

'Before, they would not have been offered rehabilitation, just a short stay in hospital. ' People stay in the nursing home for about six or eight weeks. Single assessment is not yet in operation but each patient has a common set of notes.

The changing nature of the people who need intermediate care is just one aspect that keeps the service growing and changing. As other parts of the health service and social services develop, so intermediate care must adapt. It is a dynamic service, constantly working to suit the changing needs of its clients. It constantly challenges those clients to develop their independence as well as challenging staff to let their clients do things for themselves.

REFERENCES

1 HSC 2001/01: LAC (2001) 1. Intermediate Care. Department of Health January 2001.

2 Steiner A et al . Therapeutic Nursing or Unblocking Beds? A randomised controlled trial of a post-acute intermediate care unit. Br Med J 2001; 322: 453-460.

3 Vaughan B, Lathlean J. Intermediate Care: models in practice. London: King's Fund 1999.