Editorials

Intermediate care

Appealing and logical, but still in need of evaluation

Intermediate care describes care given after traditional primary care and self care, but before or instead of the care that is available deep inside large acute hospitals.¹ It seems to address one of the limitations of many health systems: the lack of a wide range of specific and integrated facilities that can address complex needs. Going too far along a clinical pathway into a large acute hospital or remaining there for too long because no alternative facilities exist is wasteful, dangerous, and inconvenient. Examples of services that are intermediate between traditional primary care and secondary care include preadmission assessment units, early and supported discharge schemes, community hospitals, domiciliary stroke units, hospitals at home, and rehabilitation units.²

Although an important feature of intermediate care is its location, the term intermediate also refers to care that is organised and delivered by teams of different professionals and organisations. The progressive erosion of barriers between doctors and other clinical professionals, between social and health services, and between statutory and non-statutory services provides important opportunities to smooth the many interfaces throughout the system.³ The implementation of the NHS Plan makes the case for a radically different relation between health and social services, particularly in improving care for older people.⁴ As the Wanless report suggests, financial incentives may need to be strengthened to minimise blocking of hospital beds.⁵ Complex health care without hospitals should be as normal as self care without professionals.⁶

Intermediate care is compelling because it can theoretically increase throughput and capacity. Most large specialised hospitals have many bed days occupied by people awaiting discharge. The National Bed Inquiry emphasises the inappropriate use of many acute hospital beds.⁷ The issue is not the number of beds but how they are used. The prevalence of chronic disease may be rising, but that is little epidemiological justification for increasing emergency admissions: rather, for more care. Teams of specialists and clinical directors (be they from primary or specialised care) with budgets specific to programmes can bridge organisational and professional barriers and span previously fixed and inflexible budgets.⁸

Secondly, intermediate care also has the potential to offer equally effective care closer to home. Assuming the facilities and funding exist, this is good for services, carers, and patients.

Thirdly, technological evolution allows more diagnosis and treatment in the community. Information technology with NHS Direct, "near patient testing" by community staff and patients themselves, and electronically summoned assistance for vulnerable people living independently are all being developed to meet demand and need more conveniently and cost effectively.

Fourthly, if some services really are as effective outside the hospital, then this whole system approach is likely to be more cost effective.

Finally, primary care now faces the organisational opportunity to address what may be the main obstacle to modernisation and reform: the historical configuration and working practices of acute general hospitals. Integrated systems with integrated budgets (such as combined health and social care trusts) can ensure more rapid placements of people who no longer need to be in big hospitals after the acute episode. This needs a coordinated response based on evidence, cost, and patient preference, which minimises crises and where long term institutional care is a last resort.⁹

Intermediate care is an important part of modernisation. Service development needs to recognise and respond to epidemiological reality and technical opportunity. Intermediate care schemes can help shift the balance of power from secondary care to primary care and empowered self care. National service frameworks emphasise the importance of agencies developing joint investment plans, especially when improving services for older people. But the same framework reminds us that most schemes for intermediate care generate either no evidence or evidence of little effect. Evaluative evidence of intermediate schemes is scarce.¹⁰ We may be implicitly sacrificing one dimension of quality, notably long term clinical outcome, for another, such as short term convenience. Clinicians and managers should remain vigilant in balancing carefully the wishes of patients and politicians against clinical need.¹¹ Schemes for intermediate care need to avoid inefficient duplication of services in a system starved of resources.⁹ Providing alternatives to current services can easily make the system more costly, especially if an increased supply reduces thresholds for referral from elsewhere. Wholesale re-engineering that provides significant reductions in overheads is a necessary step in genuinely improving efficiency. Unlike a waiting list, which is usually an inconvenient and dangerous method of deferring demand, intermediate care can be used as a genuine way of managing demand better.¹²

Successful schemes for intermediate care seem to develop as an integrated system of professional teams where multiple assessments are avoided, the sharing of skills is promoted, and there is a single point of contact about timely access to non-hospital alternatives. There is a clarity of purpose ranging from the overall purpose of a scheme (for example, an aim to return people to their home) to the details of admission and discharge protocols. Without such clarity, the effectiveness of such schemes is impossible to assess, and the contributions of many professionals are difficult to integrate.⁸ Schemes for intermediate care are undoubtedly as difficult to evaluate as they are logical to implement. We will, however, never be sure we are increasing capacity, cost effectiveness, and convenience if we fall into the historically bad habit of believing more than we understand.

David Pencheon, director. 

Public Health Observatory, Institute of Public Health, Cambridge CB2 2SR (pencheond{at}rdd-phru.cam.ac.uk)

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