The National Intermediate Care Audit: key to understanding integrated care for older people

As John Young said at our recent older people’s services conference, ‘when we say the hospital is full, we really mean, the community is full’.

Intermediate care services are provided to patients – generally older – to help them avoid going into hospital unnecessarily, to help them be as independent as possible after discharge from hospital and to prevent them having to move into residential or nursing homes until they really need to. These services are generally time-limited, until the person has regained independence or medical stability, and are provided in people’s own homes, in community hospitals or sometimes within local nursing homes.

Intermediate care is crucial to ensuring that older people with complex needs are seen by the right service for their needs at the right time, unblocking the gridlock in acute hospitals and ensuring that life-changing decisions aren’t made prematurely about long-term care needs. There is no point performing audits of hypothetically avoidable hospital attendance, admission or bed occupancy, or stating that people should never go straight from acute beds into nursing homes, if alternative rapidly accessible capacity isn’t available. You can only define inappropriate acute bed use or care home placement by reference to what alternative services are out there. 

These services are crucial to frail older people who can rapidly lose mobility and functional independence in the face of acute illness or injury. Without adequate comprehensive assessment, rehabilitation or re-ablement they are far more likely to become permanently dependent and disabled – which, coming full circle, is bad news for systems, patients and their families. It also has the potential for ‘health’ services to reduce reliance on social care and vice-versa.

Acute hospitals have large numbers of older people who technically no longer need an acute bed – even though many did have an initial acute illness for which hospital was entirely appropriate. Two questions I ask myself on any ward round are: ‘If I saw this person on call today, would I admit them?’ and ‘Will the skills of the acute hospital team add value to what this person needs?’ We can’t deal with the emergency care crisis at the front door of the hospital without addressing the situation at the back door. There are still too many patients who could be sent home within 0 – 2 days but who would not be able to access community support in time. Older patients also present to hospital when primary care staff have tried to divert them to alternative services which are full or which simply don’t exist.

Round two of the National Audit of Intermediate Care was published last month. It isn’t specifically badged as ‘integrated care for older people’, but I will stick my neck out and say that it is the single most important document on this subject for some time – and equally important in the current debate on the crisis in accident and emergency departments  – an absolute ‘must read’. The main finding from the audit is the massive variation between localities in service capacity outside hospital and in the balance of bed-based, home-based and enabling services. It also found that we have only around half of the beds and places we need to avoid older people being in hospital unnecessarily, showing that intermediate care capacity has not improved since the publication of the 2012 audit.

The audit also found a wide range of admission or acceptance criteria (sometimes arbitrary, not necessarily based on people’s ability to benefit but perhaps on provider’s interests) and variable care inputs from doctors, nurses, mental health and allied health professionals. Many localities had a considerable amount of ’double’ and ‘triple’ running of services, essentially doing similar things for similar people but with different names, accountabilities and referral pathways. Outcomes, both in terms of the patient-reported experience measures devised by the audit team and functional independence, were equally variable. There was also a concern that people diverted to admission prevention services did not always receive full diagnostic assessment and treatment for underlying causes of functional decline.

Participation in the audit was voluntary. But I would suggest that every health economy adopts its methodology to perform a deep dive into its local services and make some hard decisions about investment and disinvestment. This should include ensuring that existing beds and places are efficiently and appropriately used – crucially, that they avoid double running of multiple services and inefficient delays caused by multiple referral assessments.  For my money, a key use of the Integration Transformation Fund would be to create extra capacity and increased responsiveness in services that come under the broad umbrella of ‘intermediate care’.

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#41200 Phil barden

It would be a terrific breath of fresh air if in analyzing the requirement for integrated healthcare for the elderly we emphasized the importance of Family responsibility - as we undervalue and reduce our expectations of family responsibility we increase the focus on medicalising the human condition

#41201 Martin Land
Leadership Associate
The King's Fund

Thanks for a really helpful blog David, and for highlighting this audit as a resource which can help as we try to reduce duplication and blockages in the intermediate care part of the system.

#41202 Liz Matthews
Managing consultant
Liz Matthews Associates

A powerful idea for me is that the appropriateness of a referral depends as much on the capacity available as it does on the nature and acuity of the patient. If we captured capacity availability more accurately we could demonstrate when capacity issues were at the forefront of determining referrals. Thanks -- thought provoking article.

#41205 Jeff Ryan
Central PHO

Good read

#41211 Alexandra Little
Strategic Planning Manager/Commissioner
NHS Dumfries & Galloway

Much food for thought - I am reminded of a time many years ago as a charge nurse in orthopaedics, working with an american doctor on an exchange programme who would ask during wardrounds "Sister, has this patient reached MHB (maximum hospital benefit) yet?

#41352 Dr M F Hasenfuss
To inform local MP re changes in & needs of NHS
Retired GPs

I have 3 major chronic illnesses.Negotiating NHS trusts to get good
treatment is a major task.Getting consultants to pay regard to all the
problems at any one time takes planning persistence & tact.We need
general physicians as well as the specialists and GPs to facilitate the integration.+MPs who are in it for the long term.

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