The audit results highlight continued wide variation across the country in the delivery of these essential community services. The audit covered half of the country’s population.
Intermediate care services are a crucial part of the NHS and social care jigsaw of services needed to meet the challenges posed by an ageing population, a rising number of patients with long-term conditions and tighter financial constraints. The audit findings show that service users of intermediate care had an average age of 82 years, with the proportion of people over 85 years increasing from 48% (2012) to 50% in 2013.
Intermediate care services are provided to patients either when they leave hospital or when they are at risk of being sent to hospital. The services offer a link between hospitals and where people normally live, and between different areas of the health and social care system – community services, hospitals, GPs and social care. The three main aims of intermediate care are:
· to help people avoid going into hospital unnecessarily;
· to help people be as independent as possible after a stay in hospital; and
· to prevent people from having to move into a residential home until they really need to.
In the 2012 audit, it was calculated intermediate care capacity needed to approximately double to meet potential demand. With the exception of two Clinical Commissioning Groups who have doubled investment in their areas, there is little evidence from the audit that investment and capacity have increased nationally in 2013. The pressure to fill existing intermediate care capacity with people leaving hospital appears to have increased, with around 70% of service users in bed based intermediate care coming from hospital wards. As a consequence, capacity aimed at preventing hospital admissions is even more limited than highlighted in 2012. The current scale of intermediate care may not be sufficient to make an impact on reducing the overall use of acute hospital beds by frail older people.
A variety of different professionals can deliver intermediate care, from nurses and therapists to social workers. The person or team providing the care will depend on the individual’s needs at that time. However, the audit raises questions about the mix of staff disciplines included in intermediate care teams and the provision of medical cover. The nursing skill mix is in line with Royal College of Nursing recommendations for basic, safe care but below those levels recommended for ideal, good quality care. Despite prevalence of dementia of between 20% and 31% in the service user age group, mental health workers are rarely included in intermediate care teams and access to specialist mental health skills is limited in some parts of the system. The audit shows that the majority of people receiving intermediate care at home or in a care home receive medical cover from their GP and do not necessarily have access to other specialists. Bearing in mind the average age of recipients of intermediate care, the role of “comprehensive geriatric assessment” (CGA) should not be under-estimated. CGA is the gold standard for effective frailty management and is known to reduce mortality, institutionalisation and hospital admission. It requires a fully staffed interdisciplinary team. Given the uneven and incomplete nature of the teams suggested by the skill mix data from the audit, it is possible that the full benefit of CGA is not being realised and that outcomes could be better if more complete teams were in place routinely.
The 2013 audit sought to focus on the quality of service provision by obtaining feedback from over 8,000 service users for evaluation. The results suggest, generally, good patient experiences and positive clinical outcomes. Comments from service users highlighted their need for support at a vulnerable time in their lives. Whilst these results are encouraging and reflect the commitment and compassion of front line staff, some findings suggest there is room for improvement in areas such as waiting times and involving service users in decision making.
Professor John Young, National Clinical Director for Integration and the Frail Elderly, Department of Health, said: “This is a large national audit of ‘care closer to home’ services that are vital for older people who are recovering from illness. It has shown that the provision of these important community services is still only about half of that needed. This is likely to be causing poor care experiences and delays across the whole health and social care system.”
Claire Holditch, Project Director for the National Audit of Intermediate Care, NHS Benchmarking Network said: “The audit provides a tool for commissioners and providers to review their services and assist them in bringing their services up to the level of best performers. Commissioners need to give serious consideration to the overall capacity of their intermediate care services and particularly to what capacity is available to prevent admissions from happening in the first place. Additional investment in services which provide care in the community is vital if pressure on hospitals is to be reduced”.
Further information about the audit can be found at http://www.nhsbenchmarking.nhs.uk/National-Audit-of-Intermediate-Care.php
For interviews and queries please contact:
1. The audit is a partnership project between the British Geriatrics Society, the Association of Directors of Adult Social Services, AGILE – Chartered Physiotherapists working with older people, the College of Occupational Therapists – Specialist Section Older People, the Royal College of Physicians (London), the Royal College of Nursing – Older People’s Forum, the NHS Benchmarking Network, the Royal College of Speech & Language Therapist and the Patients Association.
2. A report on the findings from the second year of the audit is published today. The full report can be downloaded from http://www.nhsbenchmarking.nhs.uk/projects/partnership-projects/National-Audit-of-Intermediate-Care/year-two.php
3. The National Audit Office published its report “Emergency Admissions to Hospital: Managing the Demand” on 31 October 2013. The report’s findings are in line with the concerns raised by the NAIC in terms of the availability of resources to prevent unnecessary hospital admissions and reduce length of stay through the provision of more care in the community.
4. Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a co-ordinated and integrated plan for treatment.