Intermediate care – time for a reset?

At the start of this century, a big problem facing the NHS was that too many people in need of hospital care couldn’t get in (long waiting times) and too many people in hospital couldn’t get out (delayed transfers of care). Thus began a journey of investment and reform, including a national service framework for older people in 2001. This promoted intermediate care as a flagship policy both to reduce the need for hospital admission (step-up care) and to help people leave hospital more quickly with the right support (step-down care). 

Back then, I was leading a team in the Department of Health to support the rollout of measures to reduce delayed transfers. It was a time of hope, optimism and progress. Over two decades later, there is continuing cause for celebration of the potential of intermediate care to improve the lives of older people and to reduce the need for hospital or long-term care. But at a time when the NHS faces even greater challenges than it did over two decades ago, with renewed interest in shifting care from hospitals to the community, new research raises some worrying concerns about how well intermediate care is working in practice. 

What the findings from the Networked Data Lab analysis mean 

The Health Foundation worked with the Networked Data Lab – a collaborative network of UK analytical teams using linked datasets to understand issues facing health and care services – to analyse national and local data and explore what is happening to people who use intermediate care services. 

The results require careful study, but some headline conclusions are clear. Put simply, for too many people, intermediate care is not achieving the goal of keeping them out of hospital. According to analysis of step-down intermediate care in England, 37% of people ended up back in hospital within 6 weeks of discharge. Only 25% were not readmitted within 6 weeks and had no further contact with community services. These disappointing findings may reflect the fact that the care needs of people receiving intermediate care are not straightforward. People receiving step-down intermediate care were older, had higher frailty and were more likely to have complex care needs or live alone than people leaving hospital without intermediate care. A third had died within 12 months. Yet most did not receive high intensity support – on average, people only had one to two contacts a week with community health services, for example physiotherapists, occupational therapists or care workers. The quality of discharge decision making may be another factor. 

This begs the question whether intermediate care services – and how they are designed, staffed and resourced – have become under-powered in the face of the ever-rising complexity and acuity of needs, a challenge facing all services as highlighted in the Chief Medical Officer’s report Health in an Ageing Society. This deepens the risk that intermediate care capacity is used as long-term care beds for those who are very old and unwell, as analysis by the Networked Data Lab team in Grampian appears to show.

Another cause for concern is the wide geographical variation in access to services. For example, the Networked Data Lab team in North West London found that access to step-down intermediate care on discharge from hospital ranged from 1.6% to 16.8% between neighbouring boroughs, even when adjusted for differences in patient characteristics. 

Three major questions on intermediate care 

This analysis raises three major questions for commissioners and policymakers. 

1. First, how can local services be designed with clear objectives and the right workforce skill mix? In particular, occupational therapist and physiotherapist input is crucial to achieve good outcomes for people. Otherwise, intermediate care functions merely as a hospital bed clearing service and people miss out on opportunities for recovery, rehabilitation and return to home – instead bouncing in and out of hospital.
2. Second, because intermediate care services straddle the responsibilities of the NHS and local councils and work across primary, secondary and community health services, how can these work together as a system? This must include better data sharing between health and social care and address gaps in the quality, availability and comprehensiveness of data. Without this, it will be impossible to know whether intermediate care is delivering on its ambitions and to evidence the case for change.
3. Third, how to reverse the years of underinvestment in intermediate care? Despite an abundance of rhetoric about care ‘closer to home’, numbers have moved in the opposite direction. The Darzi review pointed out that the share of the NHS budget spent on hospitals increased from 47% to 58% between 2006 and 2022. New thinking is needed about how to rebalance investment across the system.

The preparation of the new 10-Year Health Plan offers a timely and unmissable opportunity to reset the central contribution of intermediate care towards the shift from hospitals to community. It is hard to see how this can be achieved without it.  

Richard Humphries (@RichardnotatKF) is a Senior Policy Advisor at the Health Foundation.

This blog first appeared on the HSJ website.