Health and care services in the UK are under extreme pressure. People are waiting longer than ever for both ambulances and emergency admission to hospital. This is in part because there are not enough hospital beds. People are staying in hospital longer than necessary waiting to go home or for the next phase of their care, meaning less beds are available for new patients. Primary care, mental health and social care services are also struggling to meet demand. Pressures in emergency services lead to disruptions in planned care, which can fuel a cycle of worsening performance.

Expanding intermediate care services could prevent hospital admissions and help people in hospital move into more appropriate settings. As such, policymakers are looking to intermediate care services to play a key role in recovering urgent and emergency care service performance. In 2023, NHS England committed to increasing intermediate care capacity to relieve pressure in acute services, publishing a new intermediate care framework. In Wales, scaling up intermediate care was part of the goals for urgent and emergency care. In Scotland, priorities for winter included providing people with care as close to home as possible and maximising the capacity of integrated services, including intermediate care. 

To ensure intermediate care meets the needs of recipients and the health care system, we need to understand how services are currently delivered. In this long read, we explain what intermediate care is and why it is important. We use national open data to examine the state of play for intermediate care services in England. However, open data are not sufficient to help local areas understand what is needed to improve their services or inform national policy changes. Partner teams within the Networked Data Lab, funded by the Health Foundation, are working to develop local data sources to answer key questions about the delivery of intermediate care. 

Intermediate care is short-term care – generally limited to 6 weeks – aimed at maximising a person’s independence. It is either ‘step up’ to prevent someone being admitted to hospital or moving to a care home; or ‘step down’ to support someone’s recovery after a hospital stay and help prevent readmission. Common reasons someone may need intermediate care include recovery from a fall, surgery or a stroke. 

In addition to reducing pressure on acute services, intermediate care can improve independence and quality of life for patients and those around them. Evidence on intermediate care is sparse, but some small, randomised controlled trials suggest that it reduces readmissions and improves independence for people with chronic conditions compared with prolonged stays in acute hospitals. People who have received intermediate care report improved independence, confidence and mobility. 

Most people receiving intermediate care are older adults. In a 2018 national audit, the average patient age was 79 years and older across all types of intermediate care. These people often have frailty and multiple long-term conditions, such as chronic obstructive pulmonary disease (COPD), heart disease and diabetes. Over time, the health and care needs of people entering intermediate care have increased. Demand for intermediate care services is expected to rise due to our ageing population and the increasing prevalence of chronic conditions and frailty. 

Traditionally, there are four main types of intermediate care: reablement, home-based, bed-based and crisis response (Table 1).

People can be admitted to intermediate care from an acute hospital (step down) or from their home, including a care home if that is where they usually live (step up) (Figure 1). At the end of an intermediate care package, someone may need further support, or they may be ready to live independently at home. In this section, we discuss the available data on entry into and transitions between these intermediate care services in England.  

Pathways into intermediate care

Step down

Acute discharge data report the number of monthly discharges to each pathway. In 2023, an average of 303,000 people were discharged from acute hospital each month. 85% of these people were discharged home with no support, 9% were discharged to home-based intermediate care or reablement, 3% to bed-based intermediate care and 3% to a long-term care home bed. This means around 1 in 8 people admitted to an acute hospital go on to step-down intermediate care, and the majority receive this care at home. Four times as many were discharged to intermediate care than to a long-term care home placement.

Step up

People are referred to step-up intermediate care from a range of sources, including their GP, A&E, other community services and self-referral. There are no routine national open data on entry into step-up intermediate care.

Reasons for starting intermediate care

Adult social care data provide information about local authority-funded intermediate care. 

In 2022/23, 18,000 people a month completed at least one episode of local authority-funded intermediate care. Most were older adults (aged 65 years and older). Around 1 in 50 older adults in England received local authority-funded intermediate care in 2022/23. 

Reasons for receiving local authority-funded intermediate care vary by age group. The most common reason for both working-age adults (aged 18 to 64 years) and older adults is physical support, accounting for 72% of episodes for working-age adults and 92% for older adults. Working-age adults are more likely to receive intermediate care for mental health support than older adults, accounting for 16% of episodes in those aged 18 to 64 years compared with only 1% of episodes for those aged 65 years and older (Figure 1). 

What the datasets reveal about the scale of intermediate care and its pathways

Based on the acute discharge data, we know how many people enter step-down reablement or home-based and bed-based intermediate care. We also have data on the number of referrals to urgent community response services. The 2023 NHS Benchmarking intermediate care project reported the percentage of people who were receiving step-up versus step-down intermediate care. From this information, we can estimate the total number of people receiving intermediate care each month. For more information on how we calculated these estimates, please see our technical appendix. 

Each month, 27,000 people are referred to reablement or home-based intermediate care after being discharged from acute hospital (step down). We cannot distinguish between reablement or home-based step-down intermediate care. Therefore, we assumed this group was equally divided into 13,500 people receiving reablement and 13,500 people receiving home-based intermediate care after hospital discharge. The 2023 NHS Benchmarking intermediate care project reported that 18% of reablement and 74% of home-based intermediate care was step up. By combining the step-up percentages and step-down numbers, we estimated a total of 41,000 people receiving step-up reablement or home-based intermediate care (Figure 2) – 3,000 receiving reablement and 38,000 receiving home based.  

Bed-based intermediate care is mostly step down. In the 2023 NHS Benchmarking report, only around 12% of bed-based intermediate care was step up – around 1,400 people. The balance seems to be moving more towards step down over time, so that percentage may now be lower. 

In contrast, urgent community response care is mostly step up (81%). Therefore, we have estimated that of the 45,000 referrals, around 36,500 are step up and 8,500 are step down. We assumed that the urgent community response referrals were recorded as discharged home in the acute discharge data because they do not fall into the other categories. 

In total, we estimate that around 125,000 people start intermediate care services each month.

Pathways out of intermediate care

When intermediate care services are working well, as many people as possible return or remain at home after their package. However, depending on their age and frailty, some people receiving intermediate care need to be admitted to a hospital or care home if their health deteriorates.  

In 2023, an average of 7,000 discharges a month from community hospital were recorded in the community discharge data. Many of these people will have received bed-based intermediate care. This is likely an underestimate of everyone receiving bed-based intermediate care, as data are missing for many small providers. Only 28% of people were discharged home with no further support. 50% were discharged to home-based intermediate care or reablement, 7% were discharged to another community hospital bed and 14% were discharged to a care home. 

In 2022/23, 80% of people receiving local authority-funded intermediate care completed their episode and 20% finished early. Of those who completed their episode, 61% had no further services provided by the local authority (Figure 3). For most, this was because they had no identified needs, but a small number self-funded other care or declined services. 11% of people who completed their episode went on to receive short-term support, 7% received ongoing low-level support and 21% received long-term support. 

Some people move from intermediate care into an acute hospital. The NHS Benchmarking Network reported that in 2023, 11% of discharges from bed-based intermediate care were to an acute hospital. This was more than discharges to acute hospital from home-based (8%) or crisis response (9%) intermediate care. 16% of discharges from reablement care were to an acute hospital, but the sample size was small. 

Intermediate care services are being provided in an increasingly difficult environment. Many roles involved in intermediate care face severe staff shortages and retention issues. Many community hospitals have closed, and there are fewer intermediate care beds available. Over the 2010s, NHS funding increases were not sufficient to keep up with the demand for intermediate care, and there was a lack of investment in infrastructure. Local authority budgets have been shrinking for years, with growing numbers of people experiencing unmet need for adult social care services. Here, we discuss two key pressures in intermediate care for which open data are available: discharge delays and increasing costs. 

Discharge delays

Improving timely discharge from hospital has been a longstanding goal for the NHS. Delayed discharges can lead to declining mobility and cognition, increase the risk of health care-acquired infections and leave fewer beds for new admissions. Intermediate care can help by providing suitable care for someone not ready to live at home independently. However, it can also delay hospital discharge if there is a lack of capacity in intermediate care. People receiving bed-based intermediate care can also experience delays being discharged from community hospitals. 

Delayed discharges into intermediate care

In 2023, an average of 8,700 people per week remained in hospital 14 days or longer when they no longer met the criteria to reside. 24% were waiting for support at home (this should include only home-based intermediate care or reablement, but some providers may submit data that include domiciliary care), and 22% were awaiting bed-based intermediate care. Around 4,000 additional packages of intermediate care a week would be needed to prevent these delays.  

Around 24% of inpatients expected to be discharged to reablement or home-based intermediate care were delayed. Of those who expected to be discharged to bed-based intermediate care, 42% were delayed (Figure 4). These delays only include those who had been in hospital for at least 14 days. Analysis by the Nuffield Trust found additional delays related to intermediate care in patients who had been in hospital between 7 and 13 days. Therefore, our percentages underestimate the delays related to intermediate care.

Delayed discharges from bed-based intermediate care

People also face delays when they are ready to be discharged from bed-based intermediate care. In 2023, around 1,700 people a week remained in a community bed when they were medically fit for discharge. The most common reasons for these delayed discharges were awaiting availability of care at home (36%) or awaiting a permanent bed in a nursing home (25%). These statistics only include people who had been in hospital for 14 days or longer before their delayed discharge. The number of people in community hospitals is not routinely published, but the Nuffield Trust obtained this information via a Freedom of Information request. In April 2023, 22% (1,750) of all people in community hospital experienced delayed discharge. 

Increasing costs

Local authority spending on intermediate care is the highest on record, despite delivering fewer episodes of care than before the pandemic. In 2022/23, local authorities spent £477.5m on intermediate care, a real-terms increase of 11% from 2021/22 and 22% from 2020/21 (Figure 5). An average of £1,901 was spent per episode of intermediate care in 2022/23, a real-terms increase of 20% from 2020/21 and 27% from 2019/20. 

The data cannot tell us why costs are increasing, but there are a few possible explanations. The first is an increase in health care needs among people receiving local authority-funded care. Three-quarters of directors of adult social services reported that the average size of a care episode supporting a person discharged from hospital increased in 2022/23. People with greater health needs may require longer episodes of care, support from more expensive care staff or to see care staff more frequently. 

The second possible reason is social care-specific inflation. For example, increases in the National Minimum Wage (earned by many care workers) have required councils to pay more for the same amount of care. Our analysis only accounts for general inflation. 

Finally, another potential explanation is increased funding for local authorities, especially after the pandemic. Councils may have been able to offer more comprehensive episodes of care as more funds were available. They may also have been caring for people who otherwise would have received NHS-funded intermediate care because the funding was distributed via local authorities.  

Other pressures

Delays may also occur at stages of the intermediate care pathways for which no data are available, for example, waits to start step-up care and waits for assessments to determine ongoing care at the end of an episode of home-based intermediate care. 

Intermediate care services can also put pressure on unpaid carers. For example, unpaid carers may be expected to fill the gaps where there is a lack of intermediate care capacity. But this is an area with very little research or data available.

Workforce recruitment and retention is an issue across the health and care sector, including in intermediate care. As our analysis was focused on people receiving intermediate care, not those delivering it, we did not explore data on this. 

Data on intermediate care are limited and fragmented. This is unsurprising given the wide range of organisations involved in the funding, planning and delivery of intermediate care. 

There are many gaps in the insights we can draw from national open data. There is very little information about the people receiving intermediate care – for example, their health needs or socioeconomic backgrounds. This means the data cannot be used to inform decision making about what resources intermediate care services need. The available datasets also only cover certain types of intermediate care – for example, step-up care is missing. These datasets also can only tell us about activity that happens and is recorded, for example, how many people are discharged to step-down care. But we cannot determine whether the care people receive is appropriate or beneficial nor identify unmet needs. 

The open data are insufficient to interpret geographical variation. Patient-level data would allow us to explore whether differences in intermediate care services are due to differences in need between areas or indicate possible inequalities.

In their intermediate care framework, NHS England set out plans to produce an intermediate care minimum dataset. This will be a welcome addition to the open data on intermediate care. However, it will only include aggregate data and will not be able to follow patients across services. It is also likely to focus only on NHS-funded and/or provided care. NHS England is also rolling out an individual-level dataset for adult social care that will replace some of the existing aggregate adult social care data. This may help answer some questions but will still only represent the care commissioned by local authorities.   

Finally, our analysis focused on England because more open data were available. We do not know how this picture compares with the rest of the UK. We found very little data on intermediate care in Scotland and Wales. There were some equivalent data across England, Scotland and Wales for delayed discharges. But due to differences in definitions and breakdowns, the numbers of delayed discharges cannot be directly compared among countries. Scotland and Wales did not separately report discharges to intermediate care. 

Intermediate care is an incredibly valuable service that can benefit patients and reduce pressures in the health and care system. But our analysis shows that there are blockages in intermediate care pathways in England. People are facing delayed discharge from hospital due to limited capacity in intermediate care services. Our analysis suggests a minimum of 4,000 additional step-down intermediate care packages a week are needed to meet demand. People who receive bed-based intermediate care are again at risk of delays when they are ready to leave community hospitals. There is also the problem of increasing costs. Local authorities are spending more money on fewer episodes of intermediate care. This is all happening at a time when national policymakers are hoping to use intermediate care services to help restore urgent and emergency care performance. 

With their current capacity, it is unlikely intermediate care services will be able to effectively reduce pressure on acute services. In September 2023, an additional £40 million in funding was announced to ‘strengthen admissions avoidance services and boost discharge rates’ over winter 2023/24. But this is short term and may not be enough to improve intermediate care capacity in the long term given current high inflation and workforce shortages. Long-term investment is needed if intermediate care services are to effectively help patients, improve flow through the system and shift care away from hospitals. 

To improve intermediate care services, we need to understand their current state. But, as we have seen, data on intermediate care are lacking. The Networked Data Lab’s experience successfully bringing together data from different organisations and sectors can help shine a light on some of these evidence gaps. 

Our five local partner teams in England, Scotland and Wales are embedded in local health systems and therefore able to produce analyses that account for how intermediate care services are organised locally. Their analyses will bring together data from hospitals, community care and social care to answer specific questions about intermediate care that are of most interest to their local stakeholders. With these linked data, we can follow people’s care pathways between acute hospital and intermediate care services. Key questions these teams will seek to answer include how the provision of intermediate care has changed over time, the different care received by demographic groups and how often people are readmitted to hospital after receiving intermediate care. These analyses, along with an England-wide analysis of community services following hospital discharge, will be published later this year.   

Acknowledgements 

We are grateful to the members of the Networked Data Lab's intermediate care patient and public panel who took the time to review and help improve this work, including Arif Hoque, Boyd Ross, Debs Smith, Jan Davies and Victoria Lynne Wright. 

We would also like to thank Malte Gerhold and Leo Ewbank for their contributions and comments on earlier drafts, as well as Zoe Ruziczka and Chamut Kifetew for managing the overall Networked Data Lab programme at the Health Foundation. We would also like to thank everyone who provided us with feedback on our preliminary results.  

We would like to thank the NHS Benchmarking Network for providing us results from their Intermediate Care Project for inclusion in this analysis, and in particular Sarah Atkinson and Sarah Handby for their useful feedback.  

This work uses data provided by patients and service users and collected by health and social care services as part of their care and support. 

A detailed explanation of our data sources and analytical methods can be found in our technical appendix.