Dr. Duncan R Forsyth is a Consultant Geriatrician at Cambridge University Hospitals Foundation Trust. Here he tells us about the report of the fourth National Audit of Intermediate Care (NAIC) which was released 11 November 2015.
The NAIC provides a unique assessment of progress in community services aimed at maximising independence and reducing use of hospitals and care homes. Three hundred and forty services contributed to the audit with over 12,000 responses from the service user audit and Patient Reported Experience Measure (PREM). Four service categories are examined: crisis response, home based intermediate care, bed based intermediate care and reablement services.
The key themes from the NAIC 2015 are:
- Intermediate care is effective.
92% of service users maintained or improved their dependency score in both home based and reablement services. In bed based intermediate care, 93% maintained or improved their dependency score. Goals were met (wholly or partially) for more than 88% of people using health based intermediate care services, although reablement services were less likely to set goals. More than 70% return home after intermediate care and over 72% maintain the dependency level of their care setting.
- Service users generally report high satisfaction levels.
Approximately half of respondents confirmed that receipt of the service had improved their ability to maintain social contact. However, some concerns were raised by service users about communication and the need for greater involvement in setting goals. These are consistent with issues raised in previous years of the audit. Service user comments, from the Patient Reported Experience Measure (PREM) open narrative question, highlight some concerns about services ending too soon. It may be that service users’ and carers’ expectations need to be managed through better communication so that the short term nature of intermediate care is better understood from the outset.
- Capacity in health based intermediate care appears to be static – and reducing in reablement.
Given the ageing population, it is likely that demand for intermediate care has continued to grow over the four years of the NAIC. In NAIC 2012 we calculated that intermediate care capacity needed to approximately double to meet potential demand. However, over the last 3 years the NAIC has demonstrated no evidence of a material increase in capacity nationally. This gap between intermediate care capacity and potential demand would suggest that an opportunity to reduce the pressure on secondary and social care may be being missed.
- Waiting times for Intermediate Care and reablement are increasing
Average waiting times have shown a deteriorating trend over the last three years across all service categories. Average waiting times are now 6.3 days for home based, 3.0 days for bed-based and 8.7 days for reablement services. Whilst the majority of service users are waiting between 0 and 3 days, there are still some service users waiting considerable periods for services to commence. Given that one third of home and reablement service users are waiting in an acute bed, the delays represent not only a lost opportunity to reduce average length of stay but also may create a poor patient experience and impact on the effectiveness of rehabilitation.
- Staffing levels are not always optimal
The ratio of “registered nurses” to “unregistered health staff” for intermediate care units in community hospitals was close to the ratio for essential, safe care proposed by the Royal College of Nursing (RCN), although below the ideal level for good quality care. Service users commented that they felt staffing levels to be inadequate in some instances.
- Increasing evidence of integrated working between health and social care.
There is evidence of shared working between CCGs and Local Authorities as demonstrated by a step change in use of Section 75 pooled budgets (52% of CCGs; up from 38% last year). However, the real experience of integration from a user perspective comes from the effects of the so-called ‘integrating activities’. These include single point of access, single assessment process, single health record, multi-disciplinary team meetings, transdisciplinary roles and mental health staff included in the establishment. Even in those services that are badged as integrated by commissioners, these key integration activities are still far from the norm in both bed and home based intermediate care.
What next? We are considering whether we can use a simple indicator, such as ‘2-day wait’, as a barometer of community service functioning akin to the ‘4-hour’ wait for urgent and emergency care. This is evidenced based, patient centred, would serve as a measure of whole system efficiency, is simple to collect and is simple to interpret.