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Some solutions can be hidden in plain sight.
Those of us closely connected with intermediate care will certainly see these services as an important part of the solution for our overheated health and social care system, and as a platform for multi-agency working and better integrated care.
The user group is predominantly older people with multiple long-term conditions, frailty and complex life predicaments who are at a point of crisis with their health.
The core function of intermediate care is in providing alternatives to hospital care, either by preventing hospital admission or expediting discharge from hospital, using a rehabilitation-type intervention typically lasting less than six weeks. Perhaps it requires a time of austerity and an ageing population for the potential of intermediate care to be drawn into focus.
The National Audit of Intermediate Care 2014 provides this focus. It allows us to take stock; to pose and receive answers to two fundamental questions: can intermediate care deliver good outcomes at an affordable cost; and, is it making a difference?
The audit is sufficiently mature – now in its third year. It is also sufficiently large – 75 commissioners; 124 providers, 472 services; 12,022 service user responses – for these questions to be reliably tackled.
And the answers (good outcomes: “yes”; making a difference: “could do better”) are frustrating!
The audit included four service models of intermediate care: crisis response teams; home-based intermediate care; bed-based intermediate care (community hospitals and care homes); and local authority funded re-ablement services.
The outcomes of intermediate care (and bear in mind that these person-level outcome data are rarely available for most other health care sectors) are reassuringly good. Outcomes were tracked in several ways but, simply stated, the majority of users become sufficiently independent to return or remain at home.
A specifically designed Patient Reported Experience Measure (PREM) completed by over 4,600 service users described an overall care experience that is strikingly better than other health care sectors – over 90 per cent of users reported being treated with “respect and dignity”.
The PREM responses also provided some subtlety.
Patients reported a good understanding of their goals but about one third indicated lack of involvement in discussions and decisions about their care, and less involvement with the discharge process than they would have liked.
Costs seem reasonable: average costs were calculated as £1,045, £1,722 and £5,549 per episode of care for home-based, re-ablement and bed-based services respectively. The costs for home and re-ablement look particularly attractive, and the bed-based cost is similar to continued care in hospital but, of course, the person is now in a more appropriate rehabilitation environment, and a bed has been released in the hospital for a new acute care episode.
Importantly, we have good evidence from the audit that crisis response teams really can temper the pressure for emergency admissions. Only 10 per cent of the 60,384 people discharged from the 60 crisis response teams participating in the audit required admission to hospital. And the response times for these services were amazing: a national median wait time from referral to assessment of just two hours. This level of responsiveness is essential for the hyperacute nature of the frailty related presentations of falls, delirium and immobility.
Many congratulations to those teams! Surely every health and social care economy should be commissioning this type of service for its population?
And there was further reassuring evidence that the crisis response teams are well poised to support the 7-day services programme. Only 7 per cent of the crisis response services were restricted to 9am till 5pm; whereas 69 per cent offered extended hours services.
But, and it’s a big but, the three successive years of audit data confirm that intermediate care is essentially stuck. There is no hint of the necessary expansion in intermediate care capacity that is so urgently required. The national intermediate care investment is obdurately the same at around £3 million per 100,000 population (£2.3m health and £0.7m local authority).
Assuming about 30 per cent of older people who present to A&E in crisis could be cared for out of hospital if a suitable alternative service was available, and that 25 per cent of older people admitted to hospital would be suitable for an early discharge service, then the current national capacity of intermediate care is about half of that needed.
Its scale therefore remains simply too modest to make the difference that is needed across the whole system, This is despite the confidence in intermediate care implied by the audit finding that joint health and social care funding (Section 75 funding) is steadily increasing (21 per cent in 2012; 32 per cent in 2013; 38 per cent in 2014). This fundamental lack of capacity in intermediate care remains a critical choke point in the whole system, particularly for acute trusts where it will contribute significantly to delayed discharges.
Remember, when we talk about the “hospital is full” what we really mean is that the “community is full” and patients needing urgent and emergency care are spilling over into the front end of the hospital, or backed up in a queue for discharge pending the acquisition of community services.
The audit reported that the average waiting time for a place in an intermediate care service is currently six days – higher than previous years. Undue waiting in hospital is, of course, highly damaging for older people. A wait of more than two days negates the additional benefit of intermediate care, and seven days is associated with a 10 per cent decline in muscle strength, hardly an advantage for people with frailty for whom muscle weakness is a defining characteristic.
Perhaps these unnecessary waits in hospital explain the increasing lengths of intermediate care stay also reported in the audit, and so the whole system deteriorates. Yet, some hope emerges in the between-locality spread of the intermediate care investment. Some places have achieved an intermediate care commissioning value of over twice the national average. This implies that larger volume services are realistic.
This audit is an essential tool for local health and social care communities to reflect on practices. Commissioners may wish to use the information to scale up some services and merge others. For providers, incremental changes to team skills and service organisation should be considered, perhaps reflecting on the important finding from this audit that the multidisciplinary teams with the broadest team membership are associated with the best outcomes.
- Professor John Young is National Clinical Director for the Frail Elderly and Integration, NHS England
- Honorary Consultant Geriatrician Bradford Teaching Hospital Trust
- Claire Holditch is Programme Director, NHS Benchmarking Network