Stepping stones

The government has proposed a whole-systems approach to the demand for beds and an expansion of intermediate care for older people.

1Wigan is fortunate in having a long history of good joint-working in this field by Wigan and Leigh Health Services trust, Wigan and Bolton health authority and Wigan Metropolitan borough council, which are coterminous.

The desire to improve the quality of services for older people is laudable, but it is not a popular area for attracting extra resources. Once it becomes linked to the issue of delayed discharges there is a greater will to address the problem.

While delayed discharges in Wigan have generally been quite low (around eight-10 at any one time), there have been some significant blips of over 30. These are often described as 'winter pressures', but experience in Wigan suggests there is little seasonal variation, but rather year round pressures. These two factors provided the necessary impetus to develop intermediate care services.

The intermediate care service is for patients whose needs are beyond the capacity of the primary care team, but do not need the services of a district general hospital.

The service has three components:

Ambleside Bank, a short-term, purpose-built residential centre for older people, opened in 1996;

a multidisciplinary rapid-response team;

The Phillips intermediate care centre, a hospital ward providing rehabilitation and recovery.

Ambleside Bank has 30 beds, 10 day-care places, and an assessment and treatment suite for therapy staff. It is a partnership between an independent provider, and health and social services.

It aims to maintain older people in their own homes, and prevent admissions to residential care, wherever possible.

About 70 per cent of older people admitted to Ambleside Bank return home.

The rapid-response team, consisting of nurses, therapists and a social worker, was established in 1997 and accepts referrals from accident and emergency, and the medical admissions unit. The rapid-response team carries out a rapid interdisciplinary assessment, and provides follow-up care. Again, its primary aim is to prevent admissions to hospital. By December 1999 the service had been rolled out to all GP practices to allow direct access. Social services also strengthened the team through the allocation of home-care services, using the partnership grant. The team has seen a significant increase in referrals from 273 in 1998 to 390 in 1999.

The third part of the service, Phillips intermediate care centre, opened in August last year. The ward, in a nonacute hospital, offers convalescence and rehabilitation to older people. It was set up because many people were not we l l enough to be discharged from hospital to residential care and were being admitted to long-term nursing home care. They were not being provided with an opportunity to maximise their recovery through active rehabilitation.

An interdisciplinary team accepts appropriate referrals.

They provide active rehabilitation and nursing care, primarily for people in hospital who are medically stable.

The rapid-response team has access to staffed beds when they are unable to maintain someone in their own home, but they do not require an acute admission. The team has also been used to effect earlier discharges from hospital, providing nursing and therapy care. The involvement of social services allows access to the full range of health and social care services. This ensures flexibility in responding to clients' needs.

Together they are having an impact on the demand faced by the services.

These services would have little value if people were being admitted to acute hospital despite input from these teams. Box 2 shows that most people are discharged from these services to home.

Our experience has reinforced the importance of joint working at all levels. Wigan has a long history of good joint-working relationships. These developments would not have happened without the total commitment of senior managers in each of the organisations.

At the same time, senior management commitment would be worthless without the equal commitment of operational staff, who have worked together with enthusiasm and dedication. Vision must be matched with a grasp of what works on the ground.

Developing a whole-systems approach is a journey.

Each step highlights issues and alternatives for the future - can we increase shared access to services?

Could occupational therapy and home care work more closely together to promote independence? How do we ensure consistent quality in multidisciplinary assessment? Where does palliative care fit in? What role does housing have to play? These are all on the agenda for further discussion.

Staff need time to feel confident in the benefits that different types of service can provide. Phillips intermediate care centre is still establishing itself. The rapid-response team has seen a steady increase in referrals, and this is likely to continue. Thus while delayed discharges are not yet a thing of the past, we can look forward to a time when they will be.

We have learnt about tensions in partnership working.

Phillips intermediate care centre is a healthcare facility, and therefore free. People who are less dependent may be admitted to Ambleside Bank for a similar service and have to pay for it. If a support worker on the rapid-response team assists someone to get dressed it is free. If home care does this, there is an assessed charge.

At a more strategic level, jointly commissioning a new service leads to tensions between the local authority duty of best value, and the HA's requirement to seek value for money, and therefore accept the lowest tender .We have learned about the factors that strain the partnership, particularly responsibilities for delayed discharges.

Despite these tensions, relationships remain positive, and all difficulties have been overcome because of the underlying commitment to partnership working.

We have learned that we need to clarify what we mean by success. We collect figures to describe what is happening, and are pleased with the results. People are supported in their own homes. We are promoting independence in line with the government agenda. Yet how do we know if the 'right' people are coming into the right part of the system.

We have commissioned research from the Nuffield Institute to look at the effectiveness of the services in terms of targeting, throughput, interactions and further lessons to be learned.

Responding to health secretary Alan Milburn's announcement of the development of intermediate care, Age Concern expressed concern about the impact this could have on healthcare for older people.

2This is a valid worry. It is important that older people receive appropriate care, at home or in a homely setting, at the time it is required from people with the appropriate skills.

This is what we are seeking to achieve. Intermediate care is now on the public agenda. In Wigan we are ahead of the game.

REFERENCES

1 Department of Health. Shaping the Future NHS: long-term planning for hospitals and related services. Consultation document of the findings of the national beds inquiry, 2000.

2 Donnelly L. New tier of care for elderly set to follow the national beds inquiry. HSJ 2000; 110 (5690): 4-5.

Key points

A joint health authority, trust and social services approach to developing intermediate care for older people has helped keep them at home.

The initiatives have had the commitment of top managers in the three organisations.

Differing responsibilities have caused tensions in the partnerships but these have been overcome.