Intermediate care can be safe and reduce hospital use, but is it and does it?

EDITOR—Crotty et al show that transitional, or intermediate, care facilities can be used to divert older people safely from hospital to a care home setting.1 Our randomised controlled trial had similar findings,2 but we could not exclude the possibility that such transitional care increases long term institutionalisation over a longer period of follow-up (12 months, compared with four months in the study by Crotty et al). Young et al's whole system study in Leeds showed that intermediate care services increased admissions to hospital.3 So, intermediate care can sometimes reduce hospital admission and sometimes it does not. It is not guaranteed to lead to outcomes that are equivalent to those of the services being replaced.

This inconsistency of the evidence base raises the question of whether findings obtained in controlled research studies of services can be generalised to other times and settings. If not, the fears previously raised about the quality of care for older people in intermediate care services4^–5 cannot be put to rest simply because some demonstration projects have shown acceptable findings.

We need high quality randomised controlled trials, such as that reported by Crotty et al, to show what is possible, but we also need to establish the conditions that are necessary for success—those conditions that when not met lead to ineffective or unsafe care.

This is likely to require a wide range of descriptive research methods such as systems analyses and case studies undertaken alongside controlled studies. Once these conditions for success have been established, we need a systematic quality assurance exercise to ensure that they are being met.

If we do not do this then we may find ourselves so blinded by policy pressure to keep older people out of hospital that we fail to do our jobs as clinicians as we collude with the provision of substandard care.