Older people and the relationship between hospital services and intermediate care: results from a national evaluation.

In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation of intermediate care, focusing on the relationship between hospital services and intermediate care. Participants included key managers and practitioners involved in the planning, management and delivery of intermediate care in five case study sites. During the study, they identified a range of tensions between hospital services and intermediate care, including concerns about the role and involvement of acute clinicians; the safety, quality and appropriateness of intermediate care; access to and eligibility for intermediate care; a lack of understanding and awareness of intermediate care; and the risk of intermediate care being dominated by acute pressures. Although participants were able to identify several practical ways forward, resolving such fundamental tensions seems to require significant and long-term cultural change in the relationship between acute and intermediate care. Overall, this study raises questions about the extent to which intermediate care will be able to rebalance the current health and social care system and make a substantial contribution to tackling ongoing concerns about emergency hospital admissions and delayed transfers of care.

. As a result of this, there are now national targets to reduce admissions, new case managers to maintain people with complex needs in the community, and a range of different admission avoidance schemes in place throughout the country. Throughout all these debates, a key difficulty has been that any potential solution has required the support of at least three different organizations (the Hospital Trusts providing acute care, the Primary Care Trusts commissioning and often providing community services, and local authorities providing social care) as well as of many different professional groups (including medicine, nursing, social work and allied health professionals).
For many commentators, the key to tackling delayed discharge and reducing emergency admissions is to increase the amount of rehabilitation and recuperation available, particularly for frail older people who tend to account for significant proportions of emergency admissions (Blatchford et al., 1999). As the Audit Commission (2000) suggests, older people's services often experience a ''vicious circle'' (see Figure 1). As hospital admissions rise, lengths of stay decline, opportunities for rehabilitation are reduced, there is an increased use of expensive residential/nursing home care and less money for preventative services, thereby leading to more hospital admissions.
Against this background, the development of intermediate care services has been promoted as one means of breaking out of the Audit Commission's ''vicious circle''. In 2000, The NHS Plan announced an extra £900 million to be invested over four years in new intermediate care services such as rapid response teams, intensive rehabilitation services, recuperation facilities and integrated home care teams (Department of Health, 2000, 2001a. Although details were scarce at this stage, intermediate care was essentially designed to prevent unnecessary hospital admissions, facilitate swift and timely hospital discharges and prevent premature admissions to permanent residential and nursing care. While the term ''intermediate care'' is a broad one that is used to refer to a wide range of diverse services (including rapid response, Hospital at Home, step-up and step-down care home places, supported discharge, and residential/day rehabilitation), the essential characteristics shared by such services were subsequently set out in a government circular (Department of Health, 2001b), with intermediate care described as services that met all the criteria in Figure 2. Although intermediate care is a relatively new concept and area of service provision, there is now a growing evidence base (of which the study on which this paper is based is part) to help begin to understand some of the many issues that this new way of working raises (see, for example, Martin et al., 2007;Regen et al., 2008;Kaambwa et al., 2008;Godfrey et al., 2005;Green et al., 2005).
Whether the advent of intermediate care has the potential to break the Audit Commission's 'vicious circle' may very much depend on the relationship between existing acute hospital services and new intermediate care provision. Just as in the past there have been well documented tensions between community and acute care (Glasby, 2003), there is clearly scope for similar tensions to emerge in intermediate care, and the ability of new services to act as a genuine alternative to and bridge out of hospital will be significant. Against this background, this paper reports findings from a national evaluation of intermediate care relating to the emerging relationship between acute and intermediate care services. for the collection of routine data by services themselves, and clinical and managerial support for participation in the national evaluation.

This
Alongside quantitative data collection for economic analysis, in each area interviews (n ¼ 61) and focus groups (n ¼ 21) were held with key managers and practitioners involved in the planning, management and delivery of intermediate care. All interviews took place in private after written consent had been sought and interviewees had been given assurances of anonymity (data being presented in a non-attributable form). Because of this, responses were analysed and presented by case study site, rather than by the professional background of the individual participant, since this would have comprised the anonymity of those concerned in some of the smaller services and professional groupings. Interviews and focus-group discussions were tape-recorded and transcribed. The data were analysed using a method informed by the framework approach which involves the sifting, charting and sorting of material in a systematic process according to key issues and themes (Ritchie & Spencer, 1994). As a result of this, key themes were identified from the data and subsequently discussed and validated at regular research team meetings. This paper focuses on data from interviews and focus groups, and explores data relating to the relationship between acute care and intermediate care (see Kaambwa et al., 2008;Regen et al., 2008 for further details of the broader study).

Findings
Intermediate care as part of a spectrum of services and as a positive alternative to hospital For many people, the development of intermediate care had initially been driven by the need to do things differently in order to reduce pressures on acute care. This was highlighted by a range of different respondents, including those from acute care, intermediate care and social care, and including both managers and clinicians. In particular, many respondents saw intermediate care as a positive concept with the potential to promote choice, independence and quality of life. For some, this contrasted significantly with the dependency culture which they felt existed in some acute settings, and could lead to older people returning to independent living in the community in a way in which stretched hospital services would not be able to achieve. In particular, the success of intermediate care was felt to hinge on the flexibility and choice it could offer as part of a wider spectrum of services for older people.
In addition, a key feature of intermediate care was its capacity to invest time and resources in older people to help them regain their independence. Based outside hospital and in as homely an environment as possible, this was seen as preparing people to return home and as giving as realistic an insight as possible into people's self-care abilities in less institutional settings.
Difficulties in the relationship with acute care: issues for hospital staff Despite these positive perceptions of intermediate care, some staff felt that local intermediate care services had been set up too quickly with insufficient input from hospital staff. For some, intermediate care represented a new project that took funding and focus away from existing good practice, and new services too often took the form of short-term, standalone projects, insufficiently linked to mainstream services: [Intermediate care] is still perceived as a bit of an add on and to a certain extent we still have a legacy of these projects and short termisms, and the difficulty with that is when you are working with the public or service users around intermediate care that kind of impacts on your working relationship because we don't want any more projects, we don't want anymore short term things, we want something that is going to be available on an ongoing basis. (site 5) I've been around far too long, I've seen so many new schemes come and go at the expense of good sound practice . . . [Sometimes it's not because existing schemes aren't working well, but because] the government likes to have new money going to new schemes and these new schemes [are] at the expense of [existing] good practice. (site 2) For some, these concerns were also linked to fears that intermediate care might represent a lower quality form of service for older people and that new models of service provision had been set up in advance of an appropriate evidence base (about the impact of intermediate care on individual health and on wider systems issues such as delayed discharge). There were also concerns that clinicians in hospital settings may end up focusing solely on acute care and lose sight of the whole person, although some respondents felt that this constituted a more appropriate use of expensive acute capacity. For some clinicians, moreover, there was also a worrying trend towards avoiding the need for specialists -partly due to a desire to save money, but also through a desire to reduce medical power: I also feel there is a feeling amongst management in the sense that we must actually avoid specialists . . . and that means the care will be cheap. It is not, it may become more expensive. The specialists are there . . . because . . . they can actually . . . get a better outcome for the patients, not for 'oh yes the control'. There are some doctors, they are not geriatricians themselves, a lot of them feel the old school were dictatorial, but modern doctors are not dictatorial, they want to work in a multidisciplinary [team], but if you actually want to avoid them and then develop pockets of services and other things it would be a disaster. (site 1) In some services, moreover, there was a feeling that intermediate care was under-used, with intermediate care services regarded as somehow ''separate'' or ''other'' from mainstream provision. As a result, interviewees reported that many hospital staff (and indeed GPs too) lacked awareness and understanding of intermediate care services. Despite numerous attempts to promote intermediate care locally, interviewees reported that the concept had simply failed to become embedded within the mindsets of many mainstream practitioners. The rotation of hospital staff combined with pressures upon staff to find quick solutions were suggested as possible reasons for this: I just think people don't think about it naturally as it is fairly new. Services have been limited and where they are they are probably working at capacity because they are so limited so thinking of a route through intermediate care as an alternative to admitting somebody or discharge them into long-term care, people just don't think about it. (site 2) In particular, key barriers included the gradual evolution of intermediate care (with different access points and eligibility criteria) and access criteria perceived by mainstream practitioners as being too restrictive. As a result, intermediate care could by seen by some as being rather detached from mainstream services, sometimes 'cherry-picking' patients. In addition, ongoing difficulties in making referrals to intermediate care could result in practitioners reverting to other forms of service provision: Well the units . . . do develop criteria, don't they, because they have to safeguard themselves by having so many exclusions that actually they become almost impossible to use because busy clinicians can't maintain all the exclusion criteria at their fingertips. And if you refer and are rejected, next time you see a case you're going to think well, we'll do it as we always used to do. (site 1)

Difficulties in the relationship with acute care: issues for intermediate care staff
While there was general consensus about many of the issues for hospital staff set out above, some acute medical staff were also seen as resistant to change and as reluctant to refer to intermediate care for fear of losing control of their patients, and due to an ill-knowledge of what was available (which was not helped by frequent staff changes): I think the other thing is that I would like to see is that my colleagues in the hospital setting . . . feel more integrated with the intermediate care set up, which they don't at the moment . . . They don't understand what is out there and it is just so difficult to keep people up to speed with new developments and changes. (site 5) No I don't think safety is a problem, no. They just, I think these particular two [doctors] do not want to lose control of their patients. I think they see it as a threat, their patients going to somebody else, to a different Consultant.'' (site 1) In addition, hospital services more generally were felt not to understand the nature of intermediate care, and there were concerns that intermediate care could become too dominated by a desire to reduce acute pressures (not necessarily by a desire to do what is best for individual patients): [We get inappropriate referrals, particularly when there's] a bed panic, like there is today, and everybody will be told to go through the ward and find any patients and there will almost be a blanket referral Often, intermediate care staff felt under pressure to accept as many referrals as possible, even if they suspected that some were inappropriate. As a new service, trying to win over the hearts and minds of staff in social, primary and acute care, some services felt that they had to be as helpful as possible to potential referrers and had to ensure that their beds were as full as possible to justify a need for their service: And one of the real hard things for Intermediate Care is that they are damned if they do and damned if they don't all the time, at the moment. So the minute we have no vacancies in the beds, people start jumping up and down. And then the minute we have vacancies in the beds they jump up and down for the opposite reason. If we can't accept somebody on to the team from the community they jump up and down. If we get it wrong and have a problem because we accept somebody we shouldn't have accepted, or whatever . . . And that at times is very hard for the people trying to deliver. Because they do feel shot at from all directions. (site 1) There is a pressure to use Intermediate Care services for things not fit for purpose. We are already being asked to put people in Intermediate Care places where there actually is not an Intermediate Care element to that. It is to get this person out of acute hospital bed. (site 2) This task of winning over potential referrers was made more complex in one site as a result of the existence of two community hospitals, which tended to be much more regularly used by the local hospital than intermediate care. While some intermediate care services felt that they were sometimes seen as a means of relieving pressures in acute care, therefore, other services felt that they were under-utilized and were eager to receive more referrals: We are not getting as many hospital discharges as we could have because of the close proximity to the two community hospitals, certainly in the past, it is easier for the staff on the acute hospital ward to just transfer straight across than to sort out how to make the access to Intermediate Care and set that up. We have probably not been utilised as much as we could have been and that still goes on. (site 3) Overall, however, concerns from community staff about the dominance and practices of acute services were a recurring theme. As one person put it, intermediate care services ''are wary that they are a dumping ground for secondary care'' (site 1), simply existing as a means of easing pressures in acute care rather than providing more active rehabilitation.
In response, participants suggested a number of ways forward that might help to ease tensions. In particular, respondents emphasized the need for greater geriatrician involvement in intermediate care to reassure hospital clinicians about the safety and quality of services; joint work to review eligibility criteria so that these are jointly owned and disseminated throughout both primary and acute care; and the creation of joint, rotational posts, with practitioners working in both intermediate care and acute settings. In addition, various sites emphasized the need for accessible information and publicity material to raise awareness, and for more proactive case-finding and in-reach into hospital (for example, with intermediate care taking full part in discharge meetings, diverting admissions from A&E etc). However, underlying all these proposals was a sense that major cultural change will be required if hospital services and intermediate care are to work together more effectively in the future: The big cultural thing we found in particular about the intermediate care beds is hospital staff being prepared to take the risk and discharge somebody to something new that is relatively untested and unknown . . . So it is starting to overcome those barriers. Part of it is actually once somebody has put a patient through intermediate care then they have got the confidence to do it again. (site 4) I think the interface between primary and secondary care is a concept and it doesn't function really, other than as a place of passing people from one to the other by paper, or e-mail or whatever. I think our view is that you will only get a real interface if it's a working environment where there is some sort of working link between people in the community and people in hospital so that you can start to develop an understanding between clinicians of what is possible and so you can have some commonality about risk sharing and risk management . . . and the risk of intermediate care being dominated by acute pressures. At times, this seems to be very much a case of opposites -some services feeling the need to respond to acute pressures while others feel under-utilized; sometimes receiving inappropriate referrals but feeling the need to accept as many referrals as possible in order to embed the new service.
Local context often accounts for these contrasts, for example the existence of alternative discharge arrangements that bypass intermediate care, as well as the differentiation between services and between sites. Variation in intermediate care provision within and between sites meant that some services were trusted partners of acute care clinicians, others were subject to overflows of inappropriate acute patients as they became ''holding bays'' at times of pressure on hospital beds, while still others struggled to establish relationships with acute care and secure appropriate referrals in the first place. In part this was attributed to the effectiveness of information provision and communication, although it also seemed that hospital doctors were more willing to entrust the clinical safety of their patients to some services than others. This also serves as a reminder that many of the suggestions made by respondents above, about improving acute-intermediate care relationships, are likely to be fraught with political difficulties and clinical concerns, especially those which countenanced anything approaching a transfer of responsibility for hospital patients' safety.
Unfortunately, the lessons from this study are limited by the fact that we are only able to compare responses from different sites -and are not able to explore specific findings by professional background. Thus, while the study gives a strong sense of the difference in opinion between hospital-based and community-based staff, we are not able to explore this in further detail (since this would have potentially identified some of the individuals who took part from smaller professional groupings in case study sites). As a result, the current study gives an insight into inter-organizational working and into tensions between hospital and the community, but does not cover all aspects of interprofessional working more generally.
In addition to this, it is possible that some of the issues raised by participants were more to do with the complexities of joint working and of health and social care reform, rather than of the nature of intermediate care services per se. Thus, many of the specific comments made by key stakeholders above might also be the result of broader factors, such as frequent staff changes leading to discontinuity of practices and loss of organizational knowledge; staff workloads rendering ability to engage with the new system difficult; service access difficulties of a bureaucratic nature; the introduction of a new and untested system with insufficient training and piloting; the impact of unforeseen consequences (that is, the new service potentially moving blockages in the current system to another location rather than necessarily removing them altogether); and more general staff suspicion and distrust of changes. With any complex policy change such as the development of intermediate care, these and other factors are always likely to be contributing factors to the different perspectives of key stakeholders, alongside factors more to do with the nature of the policy itself and the professional/organizational culture of the individuals concerned.
While participants in the study had a range of practical suggestions as to how they might begin to resolve the issues raised, many were long-term and depended on a series of relatively small-scale approaches that might in time begin to bring about the cultural change required to improve the relationship between intermediate care and hospital services. With a 2006 White Paper focusing on the need to develop 'care closer to home' (Department of Health, 2006) and with national targets to reduce emergency admissions, however, it is not clear whether intermediate care has this amount of time available to it (or indeed the power to tackle vested acute care interests).