Comment

The 10 important features of Intermediate Care

Steph Palmerone and Mike Speakman have been looking at successes and failures in Intermediate Care. They have come to some very clear conclusions.

Everyone knows there is something wrong with the number of people we admit to hospital. Successive reviews of acute in-patient episodes in many health economies show needless occupied bed-days, extended lengths of stay and poor discharge arrangements across organisational boundaries. Decisions to admit are frequently forced by a lack of real alternatives, ill-defined pathways or admission criteria.

Unnecessary admissions create misery and disruption for individuals, families and care organisations alike – and entirely avoidable costs. People denied expert intervention at the appropriate time frequently deteriorate to a point that means hospital looks like the only alternative. The secret to avoiding this is to agree approaches for treating people in the setting with the lightest possible health service touch to ensure their needs are met (while ensuring higher-level services are accessible to anyone who truly needs them).

A national priority

The need to develop alternative services to those provided in acute hospitals is well-documented – and a national priority. At the same time, the urgent need to deliver integration of health and social care services is high on the agenda. The Better Care Fund is designed to help people think about delivery in their locality. Vulnerable older people, people with long-term conditions and people living with dementia sit in the ‘must do’ box for any commissioner or provider, but the continual financial pressures that prevent offering effective care will not abate.

The concept of ‘Intermediate Care’ was defined and advertised in the National Beds Enquiry, became a policy commitment in the NHS Plan, and was supposedly implemented in England through the National Service Framework (NSF) for Older People, with a kick-in-the-pants update in the 2009 ‘Halfway Home’ guidance.

Despite this, as the second National Audit of Intermediate Care recently highlighted, Intermediate Care is still commissioned and delivered in different ways, excludes different people and is measured in different ways.

More significantly, however, Intermediate Care is almost never commissioned at the volumes needed to have a significant impact on acute admissions. It is doomed to failure under these circumstances, particularly as good outcomes for individuals are not understood and appreciated by enough of the people who really matter.

Why confidence is low

There are many reasons why confidence in the term ‘Intermediate Care’ is low. The research we have done suggests system failures are primarily to do with confidence in managing risk. Imagine a GP ringing an Intermediate Care ‘single point of access’ number from the surgery or patient’s home. If they have to wait 20 minutes for someone to ring back or are told it will be the following day before an assessment can be undertaken, an ‘admit by default’ position is understandable.

Similarly, if a fall is being treated in a hospital A&E department and no fracture is discovered, but a urinary tract infection needs urgent treatment, an admission will often follow unless Intermediate Care teams are immediately accessible.

There is also a problem with an inability to cope with people who do not conform to neat boxes. Any effective Intermediate Care team must be able to work with an individual’s physical health crisis, whether they have dementia, a learning disability or multiple long-term conditions – all groups with high needs, who are significantly under-represented in successful treatment statistics.

Commissioners often fund pilot schemes from a range of providers in response to winter pressures or through re-ablement funds, but do not think to connect organisations together. The result is isolated providers, each working hard to do the work they are commissioned to deliver, but not aligning services or meeting to ensure a coherent service.

Ways to improve

We have had the opportunity to consider a different approach to how Intermediate Care might be commissioned. A few key features include:

1. The service must be clearly defined and readily understood by health and social care practitioners.

2. The primary function of Intermediate Care is to prevent admission to hospital or facilitate discharge, so services need to work with people who are poorly, operate 24/7 and respond quickly.

3. The service must be able to respond to the needs of clinical decision-makers in primary and secondary care.

4. There must be a single assessment process, a single care planning process and a single point of access.

5. An Intermediate Care service needs clinical oversight and at least two qualified health or social care professionals to be involved in delivering the episode of care.

6. The service must be inclusive and involve family and other key carers throughout.

7. The service should be commissioned in an integrated way and provided in a collaborative way, as a single system.

8. A single, senior manager should manage the service across organisations.

9. The service must be commissioned at volume with a set of system-wide key indicators and outcomes that reflect health and social care performance measures.

10. The GP should remain the central co-ordinator, accessing interventions and ensuring contact is maintained throughout.

There are a number of other features we would suggest are important – but if any of the above features are missing, the service will not perform.

Shared commitment and joint commissioning

The vital factors in delivering successful services are a shared commitment to transformation at a local level and to jointly commissioning alternatives to admission at volume. Commissioning a single service across a range of providers is complex but can be made a lot easier if the providers are supported in working together by commissioning systems.

While each health community will have different needs depending on health prevalence, demographics and geography, the National Audit allows typical community demand models to be developed as a basis upon which services can be quickly established and grown.

Working with the concept of an ‘episode of care’ as the commissioning currency, we have developed specifications that act as a ‘biscuit cutter’ across different services provided by different organisations. This allows for clear activity models to be developed, with an indicative cost for each episode of care. Sufficient data can be found from existing contracts to model demand on the new specification. Combined with being clear about who is eligible for the Intermediate Care service, this gives commissioners real confidence in impact across the whole system.

A genuine impact on numbers at A&E

Even the most coherent Intermediate Care service will not stop people arriving at A&E departments; but a responsive Intermediate Care service will have a genuine impact on numbers.

The new specification must respond to:

• People managed by primary care practitioners who need urgent, intensive support in order to prevent admission to hospital. This might include accessing bed-based services for a time-limited episode of Intermediate Care.

• People who need access to the technical and diagnostic services available in acute environment. In this case the key factor is offering an alternative to admission that can manage 24-hour care post-investigation.

• People who require support following an acute admission for assessment and treatment, possibly including 24-hour nursing beds to facilitate discharge from the acute environment.

Re-ablement funding and skills have a key part to play as part of an integrated single service – but some people might simply need re-ablement, while others may need to move from Intermediate Care into support for specific long-term conditions at home. The assessment must be the key to determining the most appropriate service for each individual patient, providing timely and effective transition based on individual needs.

Local decision on the contracting model

It won’t be the specification that delivers the transformation: it will be people working in different provider organisations coming together, being clear about their role in delivering the service and agreeing their measures of success. Whether the service is delivered by current providers or a new organisation must be a decision made locally. However, for most health economies it is
likely that a prime or alliance contracting model can deliver the volume, range and value for money needed.

In our experience, a well-defined Intermediate Care service can be used to support whole system transformation, can be commissioned at volume and with capacity to respond in a  timely manner to urgent and complex referrals, and can have huge potential for future delivery. It can provide a scalable, sustainable service that is significantly more flexible  than many that exist currently, deploy the limited resources we have to the best effect and deliver personalised outcomes.

As Jon Rouse, director general for social care and local government and care partnerships at the Department of Health, stated recently: “There should be no integration without Intermediate Care.”

We would argue that the service is out there to deliver alternatives to admission but it needs to be commissioned with clarity, volume and to a single set of performance outcomes. It is called Intermediate Care.

About the authors

Between them, Steph Palmerone and Mike Speakman have a wealth of experience across commissioning and provider organisations, the NHS and independent sectors, and the acute and community sectors – much of it gained at director level. Now, they each run successful consultancy practices, and work collaboratively on projects, complementing each other’s skills. Palmerone has worked at local, regional and national levels, and now focuses on developing transformational solutions, promoting integration and improving outcomes for people. Speakman has extensive experience in mental health and acute providers and now specialises in strategic change, service planning and estates & facilities issues.

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