OVER THE WALL

The best time for joint working is a period of organisational stability, with established and equivalent partners able to develop a trusting relationship.

So there has probably never been a worse time for partnerships to thrive.

The NHS and councils are coping with their biggest internal changes for years.Yet delivering partnership is a political necessity, with intermediate care the first real test.

Successfully developing intermediate care is crucial to the NHS plan but beyond the scope of the NHS alone. Drawing on a 'snapshot' in September 1999, the plan noted: 'almost threequarters of older people were not getting the care they needed because of poor co-ordination between the NHS and other agencies'. To address this, it included an extra£900m by 2003-04 for 'intermediate care and related services'.

But 'intermediate care' is still a concept in pursuit of a definition.

All manner of arrangements could legitimately claim to be within its remit, but the partnership dimension will be crucial to the effectiveness of them all. One early review of the concept notes the 'quintessential descriptor of intermediate care is its focus upon the transition from illness to health' - a move from a pathological focus (the diagnosis) to a holistic one (the functioning individual).

1In this sense, crossing organisational and professional boundaries is inescapable.

Subsequent guidance rightly emphasises intermediate care is only one component of a wider system. 'Intermediate care should form an integrated part of a seamless continuum of services linking health promotion, preventative services, primary care, community health services, social care, support for carers and acute hospital.'

2Indeed, this remit could have been further widened. The partnership challenge could hardly be more stern.

True to its centrist tendency, the government has a battery of measures for partnership performance. One 'must-do' public service agreement target is on intermediate care, with progress monitored in the performance assessment framework. Local planning for intermediate care should form an integral part of the jointly agreed local action plans for older people's services and the joint investment plans. Both will be reviewed by regional offices and social care regions. In addition, the NHS and councils are expec ted to make op t imum use of the 1999 Health Act flexibilities in formulating intermediate care services, as well as drawing on the care trust option.

Local partners will need all the support they can get to deliver this. Uncertainty remains about how much of the promised£900m will be available, and when - especially the non-ringfenced money allocated to local councils.

The NHS plan seemed to link intermediate care services specifically to older people, but guidance urges localities 'to take into account needs of all potential service users, especially younger disabled people or chronically ill patients and their carers'.

Guidance puts a six-week limit on an episode of intermediate care, with only a 'senior clinician' able to authorise an extension.

This hardly amounts to 'patientcentred care', especially with older people, who may need longer recovery periods.

Despite the sabre-rattling about care trusts, delivering intermediate care is not about structures and systems. Insofar as there is a 'system', it refers to something that forms itself around a shared purpose: the key issue is to identify and assemble the right people and organisations. This means going beyond developing inter-agency partnership to the relatively uncharted territory of inter-professional relationships.

The NHS and councils are expected to develop care pathways for the major conditions triggering acute admissions and long-stay residential care for older people. They must estimate the proportion of cases in which care and treatment could more appropriately be provided through intermediate care. The guidance stresses the importance of working in cross-disciplinary teams, and the implications for training and development, skillmix and recruitment.

Intermediate care will have to win its spurs in the subterranean zones where professionals and users are in direct contact.

Service co-ordinators will occupy a crucial 'boundary spanning' role, and be appointed jointly by the NHS and local authorities. If partnership working can win its spurs with intermediate care, it will be a prize well earned.