Intermediate Care: Poicy and Context 1 Part 1 Intermediate Care 1 1
2 Part 1: Intermediate Care 2
Chapter 1 Intermediate Care: Poicy and Context 3 Intermediate Care: Poicy and Context Jenny Cowpe Introduction The term intermediate care, as appied to eements of the British heath and socia care systems, emerged in the mid-1990s. Initiay ambiguous, with its origins predating adoption as forma government poicy, it was first recognised officiay in the Nationa Beds Inquiry consutation document (Department of Heath, 2000a). Department of Heath poicy on this subject is now contained in the 2001 Heath and Loca Authority circuar, HSC 2001/01: LAC (2001)1 (Department of Heath, 2001a) and in Standard 3 of the Nationa Service Framework for Oder Peope (Department of Heath, 2001b). What is intermediate care? Its short history is peppered with attempted definitions, refecting the evoutionary process by which the services now bearing this description have deveoped over recent years. Some essentia common eements have emerged: these services are ocay based, providing care coser to home (Department of Heath, 2000a, p. 13); they are focused on maintaining or restoring independence and are rehabiitative in nature; they are of short term duration. A key feature is the mutiprofessiona nature of the deivery teams, which are drawn from both heath and socia care. For the sake of carity, a more comprehensive definition is attempted here: Intermediate care, when fuy deveoped, comprises networks of oca heath and socia care services, which deiver targeted, short term support to individua patients or cients, in order to prevent inappropriate admission to NHS acute inpatient or continuing care, or ong-term residentia care, faciitate earier discharge from hospita and, most importanty, maximise peope s abiity to ive independenty within their communities. At present, most intermediate care services are focused on providing support for oder peope and wi generay be provided in service users own homes, or in community based settings, athough, in some instances, they may be provided in discrete faciities on acute hospita sites. Socia care is provided by statutory, 3
4 Part 1: Intermediate Care vountary and independent agencies and aso oca authority housing departments. The growth of intermediate care since the mid-1990s is a fascinating exampe of a grassroots response to oca service pressures (abeit within a deveoping nationa consciousness ), which has dramaticay infuenced the direction of Government poicy. However, its eary history, one of oca initiatives, usuay sma scae and estabished on short-term funding (and thus acking stabiity), has resuted in a wide diversity of modes: a thousand fowers have boomed (Department of Heath, 2002b, p. 5). There has been no consistent approach across the country; whie oca initiative has been a strength, the proiferation of schemes has aso ed, in some areas, to confusion and fragmentation, in turn resuting in inequaity of provision and access, dupication of effort, reduced cost effectiveness, and oss of impact (Department of Heath, 2002b, p. 5). In addition, unti recenty, there has been itte robust evauation of the effectiveness of intermediate care, and therefore no rea guidance for investment decisions. In this chapter the foowing themes are expored: The context within which intermediate care has evoved. The deveopment of government poicy on the subject. Some of the key poicy and impementation issues which require resoution in order to embed intermediate care firmy into mainstream services. Context Whist the term intermediate care is reativey new, the underying concept of inter-agency cooperation to maximise independent iving, particuary for oder peope, ceary is not. Indeed, as Swift has recenty argued in his artice on the Nationa Service Framework for Oder Peope, in successfu departments (providing speciaist medica care for oder peope) exceent partnerships with other agencies (particuary primary and socia care) and with other speciaties have been axiomatic (Swift, 2002). That being the case, why has there been such interest in intermediate care in recent years? The answer to this question ies in the compex interaction of a number of contextua factors, which coaesced in the 1990s to create a heath and socia care cimate where increased demand, and changes in suppy, produced service pressures which, aied with financia incentives, ed to a search for aternative deivery methods, both at a oca and nationa, eve which made more intensive and appropriate use of heath and socia care resources. Thus, whie oca communities expored the potentia benefits which a coser partnership between heath and socia care might bring, particuary at the interface between acute hospita care and community NHS and socia care, at a Governmenta eve there was a deveoping interest in internationa experience of aternative systems, which aso coincided with a greater focus on individua patient care. These contextua factors are examined in more detai beow. 4
Intermediate Care: Poicy and Context 5 Changes in demand A number of factors fueed an increase in demand for heath and socia care services in the ate 20th century. These incuded demographic trends, technica advances, and consumer awareness and expectations. Demographic trends In the atter years of the 20th century, demographic trends were continuing to change the underying structure of the UK popuation. Between 1981 and 1997, tota popuation increased by just 5%; interestingy, there was a drop in those aged between 65 and 74 but, and notaby, those aged between 75 and 84 increased by 18% and those over 85 increased by 80% (Audit Commission, 1997). In addition, recent estimates have predicted that, from the mid-1990s, the number of peope in Engand aged 65 and over wi rise by amost 57% unti the third decade of the 21st century and the number of peope over 85 wi rise by 79% over the same period (Vaughan and Lathean, 1999). These trends have significant resource impications for both the heath and socia care sectors, since, as is we known, oder peope are major consumers of these services. In its 1997 pubication The Coming of Age: Improving Care Services for Oder Peope, the Audit Commission noted that, whie those over 65 constituted 14% of the popuation, they accounted for 47% of Department of Heath expenditure and 48% of oca authority socia services expenditure (Audit Commission, 1997). In 2000, the Nationa Beds Inquiry found that peope aged over 65 occupied two-thirds of genera and acute hospita beds and accounted for over haf the recent growth in emergency admissions (Department of Heath, 2000a). In addition to increased pressure on acute services, oder peope tend to recover more sowy than younger peope and this paces more pressure on both transitiona and socia care services. Technica advances In addition to demographic changes, technica advances in the ate 20th century created a greater demand for chronic care support. These advances improved ife expectancy generay, but aso enabed peope with serious disabiities to extend their ifespan. They aso aowed more intensive therapies to be deivered at home, making home based care options feasibe. Increasing consumer awareness and expectations Increasing consumer awareness, knowedge and expectations have created a demand for better rehabiitation services. Consumers aso have a natura preference to be at home rather than in hospita or institutiona residentia care. As Steiner has noted, one of the attractions of intermediate care is that it focuses on the transition away from the status of patient towards the restoration of person (Steiner, 1997, p. 5). 5
6 Part 1: Intermediate Care Changes in suppy Within the NHS, the second haf of the 20th century saw a dramatic reduction in the number of NHS staffed beds for acute, genera and maternity care, which peaked at around 250 000 in 1960 but had reduced to 147 000 by the end of the 1990s (Department of Heath, 2000a). In addition, and particuary reevant to this debate, geriatric bed numbers fe from 56 000 to 30 000 over the same period (Vaughan and Lathean, 1999). This trend was taking pace at the same time as an increase in genera hospita admissions and particuary admissions of oder peope: the Nationa Beds Inquiry found that year on year, there has been continuous growth in the proportion of oder peope requiring overnight stays in hospita (Department of Heath, 2000a, p. 8). Importanty, the Inquiry aso found that for oder peope around 20% of bed days were probaby inappropriate if aternative faciities were in pace (Department of Heath, 2000a, p. 8). Whie the acute sector s abiity to manage an increasing number of admissions through reducing numbers of beds has been party attributabe to the growth in day cases, it has aso been managed through a sharp decine in the average ength of time patients spend in hospita. From 1981 to 1996/97, average acute ength of stay (per finished consutant episode) decreased from 9.3 to 5 days, whie the average ength of stay for peope over 65 decreased from 66.1 to 18.6 days (Vaughan and Lathean, 1999). Athough this decine sowed towards the end of the decade, its impact had considerabe impications for oder peope, who need onger to recover, creating pressures both within the acute heath service (bed bocking) and on transitiona and socia care support, at a time when there had aso been considerabe changes in the avaiabiity of these atter services. Before 1983, most pubicy funded socia care was provided directy by the pubic sector, through oca authority socia services residentia, day and home care and housing departments. In the eary 1980s, the avaiabiity of socia security payments for care in private and vountary sector residentia and nursing homes for anyone quaifying for suppementary benefit, irrespective of need, (rising to 2.5 biion a year by 1993), ed to a rapid expansion of this market, with independent sector nursing and residentia beds increasing by 242% between 1983 and 1996. By contrast, the number of oca authority residentia beds fe by 43%, and the provision of home care to those aged 75 and over fe by 25%. In parae, the avaiabiity of socia security monies in the 1980s enabed many heath authorities to reduce their provision for ong-term care, cosing od and outdated geriatric and psychogeriatric wards and freeing revenue for use esewhere (Audit Commission, 1997). Thus, during the 1990s, demand, particuary from oder peope, increased at a time when capacity within oca authorityprovided services was reducing. Expansion was taking pace in the independent and vountary sector, but at considerabe cost to the taxpayer. Changes in financia incentives The 1980s and 1990s in the NHS were marked by a constant search for greater efficiency and productivity, as heath organisations attempted to respond to 6
Intermediate Care: Poicy and Context 7 increasing demand within a resource imited framework. As a resut, there were considerabe incentives to encourage more economica use of existing services and to deveop new options which might reduce overa costs. The introduction, under the Thatcher Government, of the purchaser/provider spit intensified pressures to provide heath services at the owest possibe cost, whist the advent of genera practitioner and tota fundhoding created interest in service innovation and a focus on reducing hospita stays and expanding community care. In socia services, the 1990s were characterised by a number of pressures: suppy side changes (as indicated previousy); changes in funding arrangements (specificay, the capping of funds previousy avaiabe through the socia services system and their transfer to oca authorities through the Specia Transitiona Grant); and the requirement, under the NHS and Community Care Act 1990 (introduced 1 Apri 1993) to act as ead agency for arranging comprehensive packages of socia care. These combined to create a cimate of incentives to prevent premature admission to ong-term residentia community care and maximise peope s abiity to ive (reativey) independent ives within their communities for as ong as possibe. A new UK government The newy eected Labour Government in May 1997 focused renewed attention on the operation of the increasingy pressured heath and socia care systems. Major eary poicy documents such as The New NHS: Modern, Dependabe (Department of Heath, 1997b) and Modernising Socia Services (Department of Heath, 1998b) addressed the need to modernise service deivery through greater responsiveness to patients and cients needs, and by improving the partnership between, in particuar, the heath service and socia services, in order to provide seamess care. Later poicy documents have paced greater emphasis on the deivery of services coser to home (Department of Heath, 2000a). In addition, and for the same reasons, there was increasing interest in internationa deveopments in hospita bed utiisation. The Nationa Beds Inquiry noted, for instance, a number of heathcare systems in the USA operate on hospita bed days (per 1000 popuation) that are roughy haf the current Engand average and beow the rate of even the owest heath authority. Their admission rates and average engths of stay are both one-third ower than in Engand. The Inquiry aso noted that, in contrast to Engand, in some countries, notaby the Netherands, Canada and the USA, hospita admission rates for oder peope had been fat or faing for many years. In these countries, increasing pressures for emergency care are deat with in the community or in ambuatory or outpatient faciities (Department of Heath, 2000a, p. 10). Of particuar interest to the UK Government was the concusion that heath systems with ow hospita bed utiisation appear to be characterised by a arge range of ambuatory and intermediate care faciities and/or strict contro on hospita services and expenditures (Department of Heath, 2000a, p. 10), and there has been much recent discussion and anaysis of the benefits of organisations such as Kaiser Permanente in the United States (Light and Dixon, 2004). 7
8 Part 1: Intermediate Care Net effect Thus, by the mid to ate 1990s, the coaescence of the factors outined above created an environment in which both heath and socia care organisations had an interest in exporing aternative service options, both to reieve pressure on acute and residentia care and to make more efficient use of resources. In creating oca responses to service pressures, intermediate care was deveoped out of oca necessity. Poicy deveopment As indicated earier, the deveopment of intermediate care is an interesting exampe of a grassroots service response to oca pressures which has become mainstream poicy. Its history demonstrates the important interpay between oca service initiative and Government interest in stimuating an effective response to perceived service probems. The deveopment of Government poicy is traced beow. Athough its forma history is short, three phases of poicy deveopment concerning intermediate care are aready visibe: The eary phase, characterised by the search for a meaningfu definition and ad hoc service deveopments. The second phase, when the requirement to deveop intermediate care services became mainstream Department of Heath poicy and additiona funding for both heath and socia services stimuated growth and expansion. The current phase, when Government poicy is focusing on more effective coordination and integration at professiona, service and agency eve to create a whoe systems approach. The eary phase: mid-1990s to 2000 In the ate 1980s and eary 1990s, a number of experimenta schemes, aimed at rehabiitation after hospita care, and often to support earier discharge from acute hospitas, emerged on an ad hoc basis in the United Kingdom. In October 1996, a King s Fund seminar drew attention to these deveopments and to their potentia to address some of the critica system pressures faced by both the heath and socia service sectors (Steiner and Vaughan, 1996). During the ater 1990s and in 2000, a number of other agencies and bodies commented on the potentia of rehabiitation services to hep to address service pressures, incuding the Department of Heath, the (then) NHS Executive, the Socia Services Inspectorate, the House of Commons Heath Seect Committee, the Roya Commission on Long Term Care for the Edery and the British Geriatric Society. In addition, the Audit Commission pubished three reports: United They Stand (1995), The Coming of Age (1997) and The Way to Go Home (2000), which drew 8
Intermediate Care: Poicy and Context 9 Box 1.1 Intermediate care: eary poicy questions. What is it? Is rehabiitation the same as intermediate care? Is intermediate care a separate system or eve within the tota care structure? Is intermediate care an aternative to acute care or suppementary? Which types of service can be categorised as intermediate care (e.g. is rehabiitation on an acute site to be considered in this category)? Who are the target audience (i.e. oder peope ony or shoud intermediate care cover those with serious and chronic disabiities)? What is the proper ocation for intermediate care services (i.e. a bridge between hospita and home that is, not incuding home, or excuding services on an acute hospita site)? attention to the shortcomings in the way in which heath and socia services worked together to deveop services that woud offer aternative options to unnecessary hospita, residentia care or nursing home admission, or which coud hep vunerabe patients to recover greater independence foowing discharge. In parae, the Government issued a number of poicy documents, particuary Better Services for Vunerabe Peope (Department of Heath, 1997a) and Better Services for Vunerabe Peope: Maintaining the Momentum (Department of Heath, 1998a), which emphasised the contribution that rehabiitation coud make to the management of demand across the heath and socia care economy; the requirement for heath and socia services to work in partnership was aso emphasised by section 31 of the Heath Act 1999. The evoution of thinking about intermediate care services during this eary phase was marked by the search for a viabe definition of the subject, which sought to answer a series of poicy questions set out in Box 1.1. The questions themseves are an indication both of the terminoogica difficuties (compounded by different perceptions within different agencies, organisations and professiona groups) and of the variety of modes being deveoped. Athough interest was growing, there was no forma Government poicy statement about intermediate care. The second phase: 2000 to 2004 The year 2000 marked a watershed: for the first time, the description intermediate care was given forma recognition in the Nationa Beds Inquiry (Department of Heath, 2000a). The second phase is therefore characterised by increasing certainty about definition and the emergence of a cear Government strategy and dedicated funding, abeit with a particuar focus on oder peope as the target audience. The key poicy miestones in this phase are: Shaping the Future NHS: Long-term Panning for Hospitas and Reated Services. The Nationa Beds Inquiry (Department of Heath, 2000a). 9
10 Part 1: Intermediate Care The NHS Pan: A Pan for Investment, A Pan for Reform (Department of Heath, 2000b). Intermediate Care HSC 2001/01: LAC (2001)1 (Department of Heath, 2001a). Nationa Service Framework for Oder Peope (Department of Heath, 2001b). Securing our Future Heath: Taking a Long-term View. The first Waness Report (HM Treasury, 2002). Deivering the NHS Pan: Next Steps on Investment, Next Steps on Reform (Department of Heath, 2002a). Nationa Service Framework for Oder Peope Supporting Impementation. Intermediate Care: Moving Forward (Department of Heath, 2002b). The contributions of each of these poicy documents are briefy outined beow. The Nationa Beds Inquiry: 2000 The Nationa Beds Inquiry examined recent trends in acute hospita activity, comparing bed usage in the UK with internationa experience. For the UK it found evidence of significant inappropriate or avoidabe use of acute hospita beds, and in particuar for oder peope, around 20% of bed days were probaby inappropriate if aternative faciities were in pace (Department of Heath, 2000a, p. 8). Arising from these findings, the Secretary of State consuted on three scenarios for the future deveopment of care: Maintaining current direction, with no attempt to transfer services from hospita into community settings. Active deveopment of acute bed focused care, where a wider range of services, incuding rapid assessment and rehabiitation, woud be provided mainy in a hospita setting. Care coser to home, where there woud be a major expansion of community heath and socia care to support the deveopment of intermediate care services in order to avoid unnecessary admissions to acute care and to faciitate earier discharge and a return to functiona independence. Under this scenario acute hospita services woud be focused on rapid assessment, stabiisation and treatment. Option 3 was accepted, and subsequenty deveoped as part of the NHS Pan. The NHS Pan: 2000 The NHS Pan (Department of Heath, 2000b), issued in Juy 2000, contained, amongst many deveopments, proposas for a major new programme to promote the independence of oder peope through deveoping a range of intermediate care and reated services. It suggested a number of service modes, with the stated aims of: 10
Intermediate Care: Poicy and Context 11 Box 1.2 Intermediate care: expected outputs. At east 5000 additiona intermediate care beds and 1700 non-residentia intermediate care paces, together benefiting around 150 000 more oder peope each year Rapid response teams and other avoidabe admission prevention teams benefiting around 70 000 more peope each year 50 000 more peope enabed to ive at home through additiona home care and other support Carers respite care services extended to benefit 75 000 carers and those they care for compared with the 1999/2000 base ine A compared with the 1999/2000 base ine. From Deivering the NHS Pan: Next Steps on Investment, Next Steps on Reform (Department of Heath 2002a). Crown copyright. Reproduced with permission from the Controer of HMSO and the Queen s Printer for Scotand. Heping peope to recover and regain independence more quicky. Enabing easier discharge from acute care. Avoiding unnecessary ong-term care. The Pan expicity provided for an extra 900m investment by 2003/4 to support these deveopments in the heath and socia care sectors. The NHS woud receive approximatey 405m, the baance reating to resources provided to oca government, mosty for the persona socia services. Tangibe outputs expected by March 2004 from this investment are shown in Box 1.2. The expectation from these intermediate care deveopments was that inappropriate acute admissions and avoidabe deays in discharge woud be dramaticay reduced. The Pan identified intermediate care as a key test of improved partnership between heath and socia services, and the Commission for Heath Improvement, the Audit Commission and the Socia Services Inspectorate were given responsibiity for monitoring both progress towards the targets and the operation of effective joint working between the agencies. Heath and Loca Authority Circuar HSC 2001/01: LAC (2001)1 This circuar was the first detaied statement of Government poicy on intermediate care and provided initia guidance on: The definition of intermediate care and appropriate service modes. Responsibiity for intermediate care and the roe of the independent sector. Funding for intermediate care and community equipment services and charges for oca authority services. With regard to definition, the circuar was prescriptive in stating that intermediate care shoud be regarded as describing services which meet a the foowing criteria: 11
12 Part 1: Intermediate Care Box 1.3 Intermediate care modes. Rapid response: designed to prevent avoidabe acute admissions by providing rapid assessment and diagnosis for patients referred from GPs, A&E, NHS Direct or socia services and, if necessary, rapid access on a 24-hour basis to short-term nursing or therapy support and persona care in the patient s own home. Hospita at home: intensive support in the patient s own home. Residentia rehabiitation: a short-term programme of therapy and enabement in a residentia setting (e.g. a community hospita, rehabiitation centre, nursing home or residentia care home) for peope who are medicay stabe but need a short period of rehabiitation to enabe them to regain sufficient physica functioning and confidence to return safey to their own home. Supported discharge: a short-term period of nursing and/or therapeutic support in a patient s home, to enabe the patient to be discharged from acute care and to aow a patient to compete his/her rehabiitation and recovery at home. Day rehabiitation: a short-term programme of therapeutic support, provided at a day hospita or day centre. Adapted from Heath and Loca Authority Circuar HSC 2001/01: LAC (2001)1. Crown copyright. Reproduced with the permission of the Controer of HMSO and the Queen s Printer for Scotand. Focused on preventing unnecessary admission to heath or socia care faciities, and faciitating earier discharge from hospita. Invoving a comprehensive assessment and individua care pan, designed to maximise independence. Time-imited, normay asting no onger than six weeks. Invoving muti-agency input, but with a singe assessment framework and record, and shared protocos. It contained a specific framework of service modes as shown in Box 1.3. Critica to the effective functioning of intermediate care was the roe of the care coordinator, who woud have responsibiity and accountabiity for deveoping care pathways and protocos for access to services, and for ensuring that intermediate care was integrated across primary care, community heath services, socia care, housing and the acute sector. The circuar advised oca NHS bodies and councis to appoint jointy one coordinator in at east each heath authority area initiay. The Nationa Service Framework for Oder Peope: 2001 The Nationa Service Framework for Oder Peope encapsuated the Government s determination to deiver rea improvements for oder peope and their famiies. In particuar, Standard 3 was devoted to a detaied description of intermediate care services. The Standard is as foows: Oder peope wi have access to a new range of intermediate care services at home, or in designated care settings, to promote their independence by providing enhanced services from the NHS and councis to prevent unnecessary 12
Intermediate Care: Poicy and Context 13 hospita admission and effective rehabiitation services to enabe eary discharge from hospita and to prevent premature or unnecessary admission to ong term residentia care. (Department of Heath, 2001b, p. 41) The Nationa Service Framework defines the aim of intermediate care as to provide integrated services to promote faster recovery from iness, prevent unnecessary acute hospita admissions, support timey discharge and maximise independent iving (Department of Heath, 2001b, p. 41). The use of the term integrated services is interesting, refecting the Government s concern to move forward from the fragmented approach which characterised the eary phase and to avoid the confusion over definition, a strategy further emphasised by the ater statement in the document that the key to this next phase of intermediate care deveopment is integrated and shared care, incuding primary and secondary heath care, socia care, and invoving the statutory and independent sectors (Department of Heath, 2001b, p. 42). In contrast, it is interesting to note recent decisions in Scotand, where, in March 2003, the Scottish Executive made cear that they had decided not to pursue the abe intermediate care, arguing that it was uncear what distinguished intermediate care from good, patient-centred mainstream services and preferring the words integrated care (Petch, 2003). Standard 3 indicated that intermediate care services shoud focus on three key points in the pathway of care: responding to or averting a crisis; active rehabiitation foowing an acute hospita stay; and where ong-term care is being considered. Fundamenta to the successfu and effective deivery of intermediate care was: An open and effective partnership between heath and socia care agencies, invoving a commitment to joint panning and joint investment. The requirement for providers to ensure that patients offered intermediate care support had guaranteed access to speciaist assessment, diagnosis and treatment if required. The provision of care by a coordinated team, incuding, as appropriate, genera practitioners and hospita doctors, nurses and physiotherapists, occupationa therapists, speech and anguage therapists and socia workers, with support from care assistants and administrative staff. Other poicy documents Government poicy on the deveopment of intermediate care has been further emphasised in both the first Waness Report (HM Treasury, 2002) and in the second report on the NHS Pan (Department of Heath, 2002a). The former report, highy infuentia in persuading the Government to announce, in the Apri 2002 budget, investment of an additiona 40 biion for the heath service up to 2007/8, together with a 6% increase in funding over three years for the persona socia services, stated the review beieves the current baance between heath 13
14 Part 1: Intermediate Care and socia care is wrong: in particuar, care is too focused on the acute hospita setting (HM Treasury, 2002, p. 106). The atter document, whie re-emphasising the requirement to prevent hospita admission and to provide more rehabiitation, stated that athough progress has been made towards breaching the Berin Wa between heath and socia care, there are sti too many parts of the country where a faiure to cooperate means that oder peope fai to get the hoistic services they need (Department of Heath, 2002a, p. 32). This ast point was re-emphasised in the Nationa Audit Office Report Ensuring the Effective Discharge of Oder Patients from NHS Acute Hospitas, pubished in 2003, which commented on the mixed resuts to date on joint working between heath and socia services to reduce deayed discharges (Nationa Audit Office, 2003). Finay, in the paper Intermediate Care: Moving Forward (Department of Heath, 2002b), an assessment of progress to date was made, the guiding principes for intermediate care were expored, a series of usefu practica case studies was presented (together with a ist of success factors to guide impementation), and a usefu review of research evidence to date was incuded. Thus, the second phase of poicy deveopment was marked by a rapid and proific production of poicy statements. The reaity in terms of impementation, however, did not meet Government expectations. Many exampes of good practice had emerged, but there were sti numbers of heath and socia care systems where services were ess we deveoped, and where fragmentation and poor integration with other services were evident. The current phase The year 2004 marked another watershed in the deveopment of intermediate care services. As indicated above, severa major targets outined in the NHS Pan were to be achieved by March 2004; if met, much needed extra service capacity wi have been created. In addition, three major research projects on intermediate care, commissioned by the Poicy Research Programme at the Department of Heath, jointy with the Medica Research Counci, are nearing competion. These projects invove: A nationa evauation of the costs and outcomes of intermediate care services for oder peope. A comparative case study and nationa audit of intermediate care expenditure. A muti-centre study of the effectiveness of community hospitas in providing intermediate care for oder peope. Their resuts wi provide important information, and evidence, about the deveopment of intermediate care across the country, its effectiveness and comparative costs, and the outcome for both service users and carers, and for the heath and socia care systems as a whoe. As the 2002 Department of Heath paper Intermediate Care: Moving Forward stated: In many ways... intermediate care is sti in its infancy and it depends 14
Intermediate Care: Poicy and Context 15 on new ways of working within compex partnerships (Department of Heath, 2002b, p. 4). The eary, and to some extent the second, phases of deveopment have been marked by innovation but aso, in some paces, by inconsistency and fragmentation. There is a now a need, taking into account reiabe, evauative evidence, to create more coherent services, integrated across oca heath and socia care systems. Intermediate care services are quintessentiay, about partnership between organisations and professions and yet one of the reasons that peope have yet to enter into effective partnerships is that they may not know who a the partners are, or shoud be, and how they interact with each other. There is a need to understand system dynamics components and interactions both conceptuay and in quantifiabe terms (Department of Heath, 2002b, p. 6). The current phase of deveopment wi hopefuy be marked by both a greater investment in effective, inter-agency, partnerships and by the creation of coherent oca networks providing intermediate care services, where these services can ceary be recognised by their function of providing targeted, shortterm care to prevent avoidabe admission to hospita or ong-term care, of faciitating earier discharge, and above a, of enabing vunerabe peope (be they oder peope or peope with a variety of chronic disabiities) to maximise their independence. Unresoved poicy and impementation issues A number of major poicy and impementation issues remain to be resoved before the fu potentia of intermediate care can be reaised, and some of the key questions are outined beow. In terms of poicy: Is the concept and definition of intermediate care sufficienty we understood, and, if understood, accepted generay, to provide a robust patform for moving forward? Which patient or cient groups shoud be the beneficiaries of intermediate care support? Most focus to date has been on the needs of oder peope, but peope with chronic physica disabiities and peope with menta heath probems may equay benefit. Is there good evidence to suggest that intermediate care services are: deivering better outcomes for patients or cients than more traditiona modes? accepted and supported by patients or cients and by their carers (do we understand the demand paced on carers by intensive support at home)? cost effective? How is the question of charging for services (in reation to socia care) to be resoved? 15
16 Part 1: Intermediate Care What guidance, if any, is necessary to ensure that the principe of ensuring timey access to the appropriate eves of speciaist care is impemented for a users of intermediate care services? What guidance is necessary to deveop appropriate cinica governance mechanisms within intermediate care? Criticay, wi oca heath and socia care systems be abe to fund, and then sustain, the eves of investment required for effective intermediate care interventions or wi this require further Government support? In terms of impementation key concerns are: The action required to support effective partnership arrangements in areas of the country where joint working has not been effective in deivering intermediate care. The need to ascertain which modes of singe assessment work best and how they can be disseminated. The training and deveopment impications of intermediate care services. The mechanisms ikey to be most effective in disseminating exampes of good practice. The most appropriate arrangements for commissioning intermediate care. Funding remains a major hurde to the deveopment of coherent oca services. Athough both the NHS and the socia services are now receiving the considerabe extra funds promised in the Apri 2002 Budget, the issue of their aocation remains: wi appropriate sums be aocated to these services, thus reieving pressures esewhere, or wi other targets and poicy imperatives take precedence? Once again, it wi be interesting to observe the interpay between oca initiatives and deveopments and Government poicy. Summary Intermediate care must be carefuy defined in order to make sense to those who are interested in deveoping these services ocay. A genera definition is suggested in the Introduction to this chapter and the range of services now recognised under this tite are incuded in Box 1.3. In its eary deveopment phase, intermediate care emerged as a grass roots response to oca service pressures; it was ony ater (from 2000 onwards) adopted as mainstream government poicy. The major poicy statements on intermediate care are contained in the Nationa Beds Inquiry consutation document (Department of Heath, 2000a), the NHS Pan (Department of Heath, 2000b), the Heath Service and Loca Authority circuar issued in January 2001 (Department of Heath, 2001a) and the Nationa Service Framework for Oder Peope (Department of Heath, 2001b). The context in which intermediate care deveoped was shaped by a number of factors, incuding changes in demand for, and suppy of, heath and socia 16
Intermediate Care: Poicy and Context 17 care, financia pressures which created incentives for greater efficiency in resource use, and the eection of a new Labour Government in May 1997. To work effectivey, intermediate care networks require commitment and effective partnerships between heath and socia care agencies and the provision of care by coordinated teams of heath and socia care practitioners. A number of key poicy questions remain to be answered in order to obtain the maximum benefits for patients. Particuary important is the aocation of appropriate funding to deveop coherent oca networks capabe of deivering the targeted services required. References Audit Commission (1995) United They Stand: Co-ordinating Care for Edery Patients with Hip Fractures. London: Audit Commission. Audit Commission (1997) The Coming of Age: Improving Care Services for Oder Peope. London: Audit Commission. Audit Commission (2000) The Way to Go Home: Rehabiitation and Remedia Services for Oder Peope. London: Audit Commission. Department of Heath (1997a) Better Services for Vunerabe Peope. London: Department of Heath. Department of Heath (1997b) The New NHS: Modern, Dependabe. London: Department of Heath. Department of Heath (1998a) Better Services for Vunerabe Peope: Maintaining the Momentum. London: Department of Heath. Department of Heath (1998b) Modernising Socia Services. London: Department of Heath. Department of Heath (2000a) Shaping the Future NHS: Long-term Panning for Hospitas and Reated Services. Nationa Beds Inquiry. London: Department of Heath. Department of Heath (2000b) The NHS Pan: A Pan for Investment, A Pan for Reform. London: Department of Heath. Department of Heath (2001a). HSC 2001/01: LAC (2001)1 Intermediate Care. London: Department of Heath. Department of Heath (2001b) Nationa Service Framework for Oder Peope. London: Department of Heath. Department of Heath (2002a) Deivering the NHS Pan: Next Steps on Investment, Next Steps on Reform. London: Department of Heath. Department of Heath (2002b) Nationa Service Framework for Oder Peope Supporting Impementation. Intermediate Care: Moving Forward. London: Department of Heath. HM Treasury (2002) Securing our Future Heath: Taking a Long-term View. Fina Report. London: HM Treasury (The Waness Report). Light, D., Dixon, N. (2004) Making the NHS more ike Kaiser Permanente. British Medica Journa 328, 763 5. Nationa Audit Office (2003) Ensuring the Effective Discharge of Oder Patients from NHS Acute Hospitas. London: Nationa Audit Office. Petch, A. (2003). Intermediate Care: What Do We Know about Oder Peope s Experiences? York: Joseph Rowntree Foundation. Steiner, A. (1997) Intermediate Care: A Conceptua Framework and Review of the Literature. London: King s Fund. 17
18 Part 1: Intermediate Care Steiner, A., Vaughan, B. (1996) Intermediate Care: A Discussion Paper Arising from the King s Fund Seminar hed on 30th October 1996. London: King s Fund. Swift, C. (2002) The NHS Engish Nationa Framework for Oder Peope: opportunities and risks. Cinica Medicine 2 (2), 129 43. Vaughan, B., Lathean J. (1999) Intermediate Care: Modes in Practice. London: King s Fund. 18