Published: 31/10/2002, Volume II2, No. 5829 Page 24 25 26
The government has promised£900m to develop intermediate care by 2003. But the fruits of such investment are difficult to find, and some believe existing services are simply being renamed. Alison Moore investigates a precarious situation
In July 2000, the NHS plan promised that£900m would be made available by 2003-04 to develop intermediate care services for older people and reduce pressure on acute sector beds.
But are the grass roots of the NHS beginning to feel the difference?
There can be few people in the NHS who have a bad word to say about the principle of intermediate care. But there are many who are still waiting for the benefits of the massive investment apparently made since 2000 to bear fruit.
Around£255m was specified for NHS investment in intermediate care.
1Another£100m will be available in 2003-04 for a personal social services performance fund, focusing initially on the development of intermediate care.
But that still leaves nearly£550m to account for.
The Department of Health refers to the£150m available recurrently from 2000-01 for developing these services - though the NHS plan explicitly excludes this first£150m from the£900m package - and£64m for community equipment services.
Beyond that, it says, 'a substantial component of the£900m relates to resources being provided to local government, mainly through the PSS standard spending assessment'.How this element of the money is used 'remains a decision for councils to make in the light of local circumstances'.
Perhaps not surprisingly, there is a strong perception that nothing like£900m has reached the NHS and social services at local level. 'Practically everyone working in the field queries where the money is going, ' says Janice Robinson, director of health and social care at the King's Fund.
'It is difficult to track because there are lots of different monies coming in. The intermediate care money is not ring-fenced in any way. It does not appear to be coming through in the amounts expected. But I can't say categorically that the money is not there.'
NHS Alliance chair Dr Michael Dixon suggests that about half the money has 'got lost'. 'There are so many other priorities and it is a question of balancing budgets, ' he says, adding that some money has been used to fund pre-existing schemes rather than new services.
Liz Railton, Cambridgeshire county council social services director and chair of the Association of Directors of Social Services' resources committee, says: 'I do not know that anyone has a complete picture of where all the money has gone, how much intermediate care has been created and how much of it is rebadged existing services.'
Is this feeling of being short-changed starting to change as a new tranche of money from the£255m NHS money -£66m over two years aimed at capital schemes, announced earlier this year - reaches the NHS?
NHS Confederation policy manager Gary Fereday says: 'The feedback we are getting is that people are starting to see the money and it is making a difference, both in preventing people in the community getting ill and coming into hospital and enabling them to be discharged back out if they do get ill.'
But how has the money that has actually reached the ground been spent? The picture is extremely variable. In the national service framework for older people, even the DoH admitted that while intermediate care had made 'rapid progress' over the last two years, it faces 'testing challenges if it is to become firmly established in the mainstream, fully integrated into the continuum of care and realise its full potential'.
It does, however, say that by the end of 2001-02 there should be an additional 2,400 intermediate care beds and 6,200 non-residential places compared with 1999-2000. This puts it ahead of its interim target of 1,500 new beds by 2001-02. The 2003-04 target of 1,700 extra non-residential places has been easily exceeded, but there is still some distance to go to reach the target of 5,000 extra beds.
While a variety of schemes have been developed, the framework says 'there are still too many areas where services are poorly developed'.
Ms Robinson says: 'There is excellent practice around, but because of the intense pressure on authorities to get delayed discharges down there has been quite a push to find beds of almost any kind that people can go to, to release hospital beds.
'There seems to be quite a lot of rebadging of other beds going on. They are simply beds in residential or nursing homes; they are not geared up to provide for rehabilitation.'
There is also evidence that some beds are being switched from acute or rehabilitation care to intermediate care. In a survey of 114 geriatricians, Reasons for Optimism, Reasons for Concern, published by Age Concern and the British Geriatrics Society in July this year, a fifth said that beds in their hospital had been switched from other specialties to intermediate care.
2Dr Dixon says some hospitals have opened old wards and designated them for intermediate care.
Without adequate emphasis on rehabilitation, these simply fill up in a matter of days and do little to solve the long-term problems, he believes.
British Geriatrics Society president Professor Cameron Swift is concerned that some schemes do not conform to the definition of intermediate care in the framework.
'We really do see tremendous opportunities in intermediate care but its governance, both financial and professional, needs to be set in order, ' he says.
His concerns are likely to be echoed in a report from the Royal College of Physicians on intermediate care, which is due out later this year.
Nonetheless Professor Ian Philp, national director of older people's services, maintains that the number of beds being developed is ahead of target and that rebadging has only affected 'a tiny minority' of beds. And he has warned against doctors undermining developments in intermediate care simply because they are not involved in them. 'Intermediate care has huge momentum and investment behind it. There is no doubt in my mind that we are on course, ' he says.
Many intermediate care schemes provide support in the community or in community-based beds, rather than on the fringes of the acute sector. Input from district nurses, GPs and community geriatricians is vital.
But the number of district nurses has declined in the last five years and GP numbers are barely moving, says Dr Dixon.Without attracting these key staff, expansion of community-based schemes may be compromised.
The Age Concern/British Geriatrics Society survey suggested that links between intermediate care and hospitals were sometimes weak and there was no geriatrician involvement in daily clinical management in nearly two-thirds of schemes.
Could the independent sector provide more beds?
The Independent Healthcare Association says it is being stymied by short-termism among commissioners and 'patchy and inconsistent' involvement on the ground which inhibits investment by the private sector.
The Commons health select committee has given some credence to this view, calling for the private sector to be involved in developing care and support services. There are places where this has happened - in Leeds three-year contracts have been developed, and Bupa has a scheme in Dudley where it provides nursing and personal care - the NHS sends in therapists and the local authority contributes social workers and home-care teams on discharge.
Ms Robinson says there has been a 'hesitancy' within the NHS to place contracts with the independent sector.
'People working in hospitals have a huge allegiance to keeping things within the hospital rather than putting it out in the community. That will push the independent sector out as well, ' she says.
In the early stages of developing intermediate care, new schemes involving the independent sector were either cancelled or did not get off the ground in the first place, according to the IHA report Engaging the Independent Sector in the Development of Intermediate Care, published in April 2002.
3Bupa Care Services medical director Dr Clive Bowman says: 'We have been disappointed by progress.Most of the contracts that we have had have been fairly short term and a natural expansion of winter pressures programmes, rather than truly innovative initiatives.'
He argues that the NHS has not yet understood that intermediate care will mean major investments in buildings, rather than just beds: care-home bed occupancy has risen dramatically in four years.
Has investment in intermediate care services relieved pressure on acute services? One of the reasons for developing these services is the cost and effect of delayed discharge: the health select committee recently suggested that delayed discharge was costing the NHS£720m a year and taking up 6 per cent of hospital beds.
4The National Audit Office - which is currently examining delayed discharge - says 5,000 people over 75 were affected in the third quarter of 2001-02.
Anecdotally, many NHS staff believe intermediate care reduces demands on acute beds at a reasonable cost, but there have been too few comprehensive studies to back this up.
The research reviewed in Intermediate Care: moving forward, published by the DoH in June 2002, gave a very mixed picture of both impact on the rest of the NHS and cost.
5A hospital at home service, for example, may be as expensive as inpatient care and nurse-led units may lead to increased length of stay.Day hospitals might help to keep people out of acute beds, but the review concluded that the evidence 'is not sufficiently robust to allow dogmatic conclusions'.
Certainly, intermediate care by itself will not solve the problems of delayed discharge: an extra 2,400 beds by the end of this financial year is only eight beds per primary care trust. Last winter some large trusts, serving two or three PCTs, had upwards of 60 delayed discharges.
Unless people are helped to move out of the hospital system altogether, any benefit may be short-lived.
'It feels a bit like pedalling fast to stay still, ' says Ms Robinson. 'To really make an impact, something needs to be done at the front end of the system to stem the flow of people into hospital when it is not necessary.'
The NAO report, due out early next year, and two DoH-sponsored studies due out in 2004, may shed some light on whether intermediate care money is easing pressures - and at what cost. l In detail: what is intermediate care?
The NHS plan was short on intermediate care detail, but further guidance was given to both health authorities and local authorities in 2001.
1,6 Circulars described a number of models for intermediate care:
rapid response offering short-term nursing, therapy and social care in a patient's home to prevent avoidable acute admissions;
hospital at home - intensive support at home, including investigations and treatment, to prevent admission or facilitate discharge;
residential rehabilitation in community hospitals, rehabilitation centres, nursing homes or care homes: therapists should be involved, where appropriate;
supported discharge where patients are given nursing and/or therapy services, plus home care;
day rehabilitation involving therapeutic support.
The guidance stressed the need for joint working between health and social services, and said the potential role of the private sector should be taken into account.
The national service framework for older people suggested that intermediate care should be for six weeks or less - and said intermediate care should be considered:
when responding to or averting a crisis;
as active rehabilitation following an acute-hospital stay;
where long-term care is being considered.
Praise where due: how investment can pay off Older people's 'czar'Professor Ian Philp has praised Liverpool's intermediate care services as examples of well-planned, integrated services - but they do not come cheap.
Nicola Allen, intermediate care manager for the Central Liverpool primary care trust - which runs many of the city's services for other PCTs - says the cost of all the NHS and city council schemes is around£5.5m a year.
The services, which have been developed over the last six years, include:
twenty-eight beds in a community hospital, which are multi-disciplinary-led with clinical support from a local GP;
thirty intermediate care beds in an acute hospital which are nurse-managed;
around 20 beds in two social services residential homes;
an emergency response team of nurses and domiciliary workers which will assess and care for people for up to 72 hours to prevent admission to hospital.
The team also works in the accident and emergency departments of the city's two major hospitals, offering an alternative to patients who would otherwise end up being admitted to the wards.
Around 40 beds are commissioned through the independent sector, on an 18-month contract.The service includes:
a rapid response team that can offer social care for up to six weeks to people who have been initially cared for by the emergency response team;
a specialist team caring for people with chronic chest problems who would otherwise be admitted;
a 'tracker nurse team' which identifies patients likely to benefit from intermediate care at an early stage once they are admitted to hospital, and pave the way for their eventual discharge.
Many of these services - including those in the independent sector - call on a central team of nurses and therapists to provide care: there is also a nurse consultant in intermediate care.There is a single point of contact for the intermediate care service, which can be accessed by health and social care professionals throughout the city.The role of the intermediate care co-ordinator is essential for the smooth-running of the system.
Ms Allen says the scheme benefits from clear clinical leadership, senior management support and a willingness of colleagues to 'champion' intermediate care throughout the healthcare system.But, though there is agreement that the schemes have made a difference to the acute sector, that is hard to demonstrate.'We are still trying to understand the impact, ' says Ms Allen.'It is very hard to quantify intermediate care's contribution but it does now seem to be valued by the acute sector.'
1Health service circular.
Intermediate care.HSC 2001/001. Department of Health, 2001.
2Reasons for Optimism, Reasons for Concern. Age Concern and the British Geriatrics Society, July 2002.
3Engaging the Independent Sector in the Development of Intermediate Care.
Independent Healthcare Association, April 2002 [cited 17.10.02] www. ihs. org. uk/EISDIC. pdf 4Health select committee.
Third report. Stationery Office, 2002.
5Intermediate care: moving forward. Department of Health, July 2002 [cited 17.10.02] www. doh. gov. uk/ intermediatecare/ icmovingforward. htm 6Local authority circular.
Intermediate care. LAC (2001)1. Department of Health, 2001.