INDETERMINATE CARE – The reality behind Intermediate Care

1. Introduction

1.1 Intermediate care has been defined as a short period of rehabilitation and therapy to promote independence . The Government claims it will improve care for older people and reduce waiting time targets. However, intermediate care without therapists or active rehabilitation becomes little more than a cheaper form of delayed discharge, warehousing older people.

1.2 To find out more about the development of intermediate care services, Paul Burstow MP, Liberal Democrat Frontbench Spokesman on Older People, conducted a survey of Primary Care Trusts. It was sent out to all PCTs in England (166), and 85 responses (51%) were received, with 73 responding fully giving a response rate of 44% (surprisingly high, given the present reorganisation).

1.5 The main findings of the survey were that:

· The focus was too much on delayed discharges. Some old hospital wards were simply reopened and renamed "intermediate care beds".

· There were difficulties in implementing government guidance. More than 7 out of 10 of respondents felt the time limit was inflexible or too short.

· Many social services departments were charging for some parts of intermediate care, despite guidance to say it should be free at the point of delivery.

· A national shortage of therapists

1.6 Further research for this report has uncovered major confusion over the allocation of funding for intermediate care. The question is how much of the funding was eventually spent on intermediate care, and it seems that no one, not even the Government, knows the answer.

2. Charging

2.1 According to the Government, intermediate care should be provided "free at the point of use". This means that local authorities should not charge for this service. However, our survey results show that many social services departments have been charging for some services as part of intermediate care packages.

2.2 The Government has been unclear on charging. In a written answer to Paul Burstow MP, Health Minister Jacqui Smith stated that the Government believes "that all intermediate care … should be free at the point of use … Although councils retain local discretion to charge we are encouraging them to make all such services free at the point of use".

2.3 However, in a written answer to Baroness Barker, Health Minister Lord Hunt stated that the circular mentioned above "is statutory guidance … We expect local authorities to comply with statutory guidance and have no special arrangements to monitor whether or not local authorities are charging for intermediate care services" . While one Government Minister is "encouraging local authorities" another expects them "to comply". No wonder local authorities are confused!

3. The Survey Results

3.1 Many respondents reported difficulties in evaluating intermediate care provision in their area. Difficulties including cross-agency working, boundaries between agencies, and incompatibility of IT systems. There were also differences of opinion in the definition of intermediate care ... "it is a complex picture".

3.2 Many schemes were only just being set up, or were still at pilot stage. Some were on a very small scale, treating as few as 10 patients. From those schemes that had managed some evaluation of their work, however, signs were encouraging, showing many patients were enabled to return to their own homes.

3.3 Most intermediate care co-ordinators understood the benefits of the service, in promoting independence and care closer to home for older people. It was worrying, however, that many respondents were fixated with the benefits of relieving pressure on acute care, and solving "bed-blocking" … one respondent claimed that intermediate care was important because "it enables acute trusts to meet waiting list targets".

3.4 Intermediate care was being provided in a range of settings, at home, in community hospitals, day centres and residential homes, run by the private and voluntary sectors or by local authorities. 11% of respondents said that some new intermediate care beds were simply the result of reopening closed acute hospital wards. This simple reopening of old beds is not the kind of new panacea the Government is claiming.

3.5 The strict Government definition of intermediate care as lasting for a period of six weeks came under criticism from many quarters. 36% of respondents believed this was unrealistic, and a further 34% thought it might be realistic in the majority of cases, but that there needed to be more flexibility. The reasons were that individual patients had vastly varying diagnoses and responses to treatment, and this time period was too short, especially for those with mental health needs. There were also concerns that after six weeks, patients would be charged for extra care, or would not be given further treatment:

"Timescales and rigid rules lead to added confusion and worry for patients and added bureaucracy for staff".

"It would be easier to manage if all care, both social and health, was free at the point of delivery".

"Physiotherapists (believe)… another couple of weeks would make all the difference".

3.6 Some inferred that the time limit was there simply to keep the system moving. Patients would be discharged from intermediate care after six weeks, so that their places could be given to someone else, no matter how quickly they responded to treatment.

3.7 The biggest barrier to intermediate care is the huge shortage of therapists. 88% of respondents had difficulties recruiting therapists, particularly physiotherapists and occupational therapists. The problem was due to national shortages, but also the difficulties of recruiting staff to work with older people. Also, because intermediate care is such a new style of treatment, it is still not completely recognised as a discipline.

"Huge problem!" "Constant difficulties" "We have had enormous difficulties".

"It's proving impossible to fill all vacancies".

"To recruit you appear to be borrowing from other areas".

3.8 Alarmingly, 43% of respondents said there was some charging for intermediate care services in the last year. Some also said that charges would be continued for the foreseeable future. Often, the local authority social services departments were charging for hotel costs, and social care elements of intermediate care packages, but there were also flat rate charges per bed. One respondent believed that under government guidance they were "still entitled to" charge patients. (See section on charging).

3.9 Some models of service delivery wandered sharply off the Government's definition of intensive therapeutic rehabilitation, with schemes such as tai chi classes and a handyman being classed as intermediate care.

3.10 There was a serious lack of appropriate specialist provision for mental health needs in intermediate care. Only 12% of respondents had specific beds or places for older people with mental health needs and only 26% had staff with mental health training.

4. Is Intermediate Care Working?

4.1 The Government has repeatedly claimed great things for intermediate care:

We will: "provide high-quality pre-admission and rehabilitation care to older people to help them live as independently as possible by reducing preventable hospitalisation and ensuring year-on-year reductions in delays in moving people over 75 on from hospital."

4.2 The Government then set targets for additional intermediate care beds and places. However, there is no monitoring of the quality of care provided or the outcomes achieved. A written answer received by Paul Burstow MP stated that basic information, in this case the number of people admitted to hospital following an episode of intermediate care, is not available .

4.3 There is a danger that patients will be shunted into "intermediate care provision" without the therapy and treatment necessary to make intermediate care work. Our survey highlighted the shortage of therapists, and the problems some areas were having over defining intermediate care. According to an answer to a parliamentary question from Paul Burstow MP, in just two years (1999 to 2001) the vacancy rate for speech and language therapists has increased by almost 300%. Over the same period the vacancy rate for physiotherapists increased by around 230% .

5. Where has all the money gone?

5.1 The Government announced "£900 million by 2003/4 for intermediate care and related services" in the NHS Plan.

5.2 The funding was further explained in the Department of Health guidance on intermediate care, published in January 2001 . Investment would be divided between the NHS and local authorities, and should be spent under shared budgets .

5.3 According to the guidance, the NHS should receive £405 million for intermediate care. The problem arises with the money that is supposed to go to intermediate care via the SSA - the Social Services Standard Spending Assessment (the usual vehicle for funding Social Services).

5.4 It has now emerged that Local Authority Social Services have received no extra money to that set out in the 1998 comprehensive spending review . This review took place two years before the Government pledged extra cash for intermediate care as part of the NHS Plan (July 2000). Effectively the Government are insisting that intermediate care be prioritised by Social Services but are not providing them with any additional funds - whilst having pledged publicly that they would do so. This has been compounded by the fact that the Government did not reveal that existing budgets must be stretched in this way until January 2001 (only 4 months before the start of the next financial year) .

5.5 The full horror of the situation becomes clear when one realises that the extra cost to Social Services of providing intermediate care in 2002/03 is £270 million. Given that the SSA increase for all Personal Social Services is only £475 million the Government should make clear what services would be cut to ensure that intermediate care is paid for.

5.6 The question is how much of the funding was eventually spent on intermediate care, and it seems that no one, not even the Government, knows the answer. It is clear that this aspect of funding for intermediate care should be the subject of an audit. Paul Burstow has written to the National Audit Office to request an investigation into the matter.

7. Conclusions and recommendations

7.1 This report shows that too much emphasis has been placed on intermediate care as the solution to delayed discharge, to the detriment of the understanding of its benefits to the patient.

7.2 Obtaining a clear picture of intermediate care services is very difficult, due to the variation in provision and lack of understanding of intermediate care services. Many services are still at pilot stage, or have only recently been set up, and there is still a great deal of confusion over what intermediate care is, and why it is important.

7.3 This survey has highlighted that it is impossible to effectively begin national implementation of intensive therapeutic rehabilitation with a national shortage of therapists.

7.4 More clarity is needed over the issue of charging for intermediate care. The Government guidance states that it should be free at the point of delivery, but there is no control over local authorities to stop them charging for services. Our survey shows that charging is still an issue in many areas. This problem can only be solved when there is more clarity over the true level of funding for intermediate care provided to local authorities.

7.5 Seeing intermediate care as the solution to the problems of social services departments and primary care trusts in providing appropriate treatment for older people, is only half the story. Unless the Government sorts out the years of under-funding in social services, and provides adequate support for local bodies in setting up intermediate care, this great opportunity could be wasted.

Appendix I: Extract from Department of Health Guidance: HSC 2001/01 : LAC (2001)1

The Department of Health intends to adopt the following standard definition of intermediate care. Intermediate care should be regarded as describing services that meet all the following criteria:

a. are targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care;

b. are provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery;

c. have a planned outcome of maximising independence and typically enabling patient/users to resume living at home;

d. are time-limited, normally no longer than six weeks and frequently as little as 1-2 weeks or less; and

e. involve cross-professional working, with a single assessment framework, single professional records and shared protocols.

Appendix II:

NHS Plan targets:

· Promote independence through active recovery and rehabilitation services with an extra 5,000 intermediate care beds and a further 1,700 supported intermediate care places, together benefiting around 150,000 more older people each year

· Prevent unnecessary admission to hospital with extra rapid response teams and other forms of admission prevention benefiting around 70,000 more people each year

Key National Service Framework for Older People milestones:

· July 2001: appoint intermediate care co-ordinator for each health authority

· January 2002 - joint investment plan locally for 2002/3

· March 2002 - at least 1,500 additional intermediate care beds

· March 2004 - at least 5,000 additional beds plus 220,000 additional people receiving intermediate care, compared to 1999/2000 -150,000 of which promote rehabilitation and supported discharge, and 70,000 of which prevent unnecessary hospital admission.