Strategic planning in Intermediate Care is needed to “unstick” the NHS
Prof John Young is a Consultant Geriatrician in Bradford, UK and National Clinical Director for Integration and Frail Elderly at NHS England. Here he reflects on the 2013 National Audit of Intermediate Care. The full audit report can be found here.
I have been closely involved with the National Audit of Intermediate Care since its inception in 2008. The journey has been challenging but highly rewarding. The audit now covers about half the NHS – remarkable when you consider the commitment required by local staff to collect and submit the data.
The audit is important because it describes services that are otherwise relatively hidden from view in our conventional perception of health and social care. Yet intermediate care, or “care closer to home,” has been quietly developing during the last ten years or so. The focus has always been that of older people with co-morbidities/frailty – just the group that is now so much in the forefront of health and social care thinking. And intermediate care services have always been a platform to develop new ways of working – particularly multi-agency working – and so it is highly relevant to our current interest in service integration.
Patient experiences of intermediate care services
There are many ways of benchmarking services like intermediate care but arguably the foundation stone should be the care experiences of the service users. Thus the novel introduction of the Patient Reported Experience Measure (PREM) in the audit is brave and highly informative. It was carefully developed and presented in the form of ‘I’ statements as recommended by National Voices. So did intermediate care pass this fundamental test? It depends! It depends on how high we aspire to set the bar. I suggest we set it at 95% of patients reporting positive experiences. High? Possibly, but this still means one in 20 people are reporting a negative aspect of care. Against this standard, intermediate care as a whole is not yet delivering the type of service patients hope for.
Intermediate care capacity
“The hospital is full” has become a dependable barometer for the NHS and is increasingly popularised by our media. “The community and social care is full” is arguably a more truthful statement. In a whole system, we are vulnerable to the weakest link. The audit has demonstrated that the current provision of intermediate care is around half of that required to avoid inappropriate admissions and provide adequate post-acute care for older people. Moreover, the 2013 audit showed that intermediate care capacity appears stuck – with no change compared to the 2012 audit.
Perhaps this is unsurprising because the audit also found clear evidence of weak local strategic planning processes. This is likely to be the explanation for the long waiting times to access these services by patients (3.4 days for bed-based services; 4.8 days for home-based and 4.2 days for enabling services). Delays are counterproductive for older people who rapidly deteriorate when held in a queue and inevitably spend longer in the intermediate service whilst their capabilities are brought up to previous baseline. Strategically planned, adequate intermediate care capacity should be an essential step for local health and social care commissioners if the whole system is to function optimally.
It has now been fully recognised that the current situation of silo working and fragmented health and social care services must be rectified. National Voices on behalf of service users have provided a laudably simple definition of integration: care that is “person centred and co-ordinated”. So how is intermediate care doing in respect of integration? A mixed picture is presented in the audit – probably a fair reflection of some progress, but much more work to do. The crisis response teams and home based services appear to be well integrated into the wider health and social care systems with referrals received from primary, secondary, community and social care sources.
There do however appear to be opportunities for re-ablement services to become more integrated with the whole system (43% state that they are currently operating separately from intermediate care services). There is evidence that the services are running in parallel with the ‘health’ intermediate care being underpinned by ‘health’ referrals and a trivial number of referrals from social care, whereas social sector referrals comprise an important source of work for the enabling services. Perhaps this parallel service provision is unsurprising given that the Section 75 pooled budget funding opportunities has been taken up by only 32% commissioners in the audit (albeit up from 21% in the 2012 audit).
Where does mental health fit in? Not at all, it seems. The proportion of mental health trained staff in any of the service models audited is so small as to be miniscule, and training in dementia care – surely essential for staff working with older people? – is deficient as only about half the staff has received this training. So, strategically and operationally, the integration agenda has yet to be addressed.
I hope next year’s audit will show across the board improvements in these key areas.
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