Prof John Young is the National Clinical Director for Integration and Frail Elderly for NHS England. He is an Honorary Consultant Geriatrician, Bradford Teaching Hospitals and Head of the Academic Unit of Elderly Care and Rehabilitation at the University of Leeds. Here he updates his recent commentary published in Age and Ageing journal.
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. 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), and sufficiently large (75 commissioners; 124 providers, 472 services; 12,022 service user responses), for these questions to be reliably tackled. And the answers are frustrating!
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. The majority of users become sufficiently independent to return/remain at home. The patient reported care experience is strikingly better than other health care sectors (over 90% of users reported being treated with “respect and dignity”). 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% 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?
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. Its scale, from a whole system perspective, remains simply too modest to make the difference that is needed. This is despite the apparent system wide confidence in intermediate care implied by the audit finding that joint health and social care funding (Section 75 funding) is steadily increasing (21% in 2012; 32% in 2013; 38% 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 demonstrates that there is insufficient intermediate care capacity for a prominent presence in A&E (an estimated 30% of acute admissions might be avoidable), and 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% 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 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. There is emerging evidence that the Better Care Fund that is expected to link over £5 billion of health and social care spend will include new intermediate care services.
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 teams; 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. Individual teams should take note of the PREM findings (similar to last year) that many users of intermediate care services report less involvement with care decisions than they would like. High quality care planning as an effective intervention for older people (Cochrane review to be published soon) is in the limelight right now. An alliance has been formed, the Coalition for Collaborative Care, to improve care planning nationally. As Nigel Mathers, GP and Honorary Secretary of the Royal College of General Practitioners puts it: “The Coalition has been set up to change the relationship between people with long-term conditions and the health and social care practitioners they work with on a day-to-day basis. We want to put this new relationship at the heart of the way that services are provided.” This is important for us geriatricians as “…people with long-term conditions …” are, of course, our patients.