Intermediate care benefits older people despite limited funding

English audit reveals 90% of patients either improve or maintain their independence after an episode of care

An audit carried out in England reveals 90% of patients either improve or maintain their independence after an episode of care

Nurse Clifford Kilgore: 'intermediate care takes into account the whole person'. Picture: Chris Balcombe

The NHS has spent the winter battling to free up hospital beds. Escalation wards have been opened and attempts have been made to speed up the discharge process. However, hospitals have still struggled to cope with bed occupancy rates remaining high.

Could intermediate care provide the solution? Many think so. A recent audit of services in England by the NHS Benchmarking Network reveals that, despite limited investment, they are having a significant effect.

It looks at four types of intermediate care:

  • Bed-based.
  • Home-based.
  • Crisis response.
  • Reablement.

Feedback was received from more than 12,000 patients, while half of clinical commissioning groups (CCGs) and one third of councils responded.

£2.8 million

Amount spent on intermediate care per 100,000 people

Overall, the audit found nine in ten patients either maintained or improved their level of independence after receiving intermediate care.

Where there was improvement – in three quarters of cases – the level was judged to be significant. The findings show an average percentage improvement in dependency levels of 31% during home-based care, 35% for bed-based care, and 36% for reablement.

More impressive result

The improvements were similar to 2015, which was the last time the audit ran. But it was judged to be an even more impressive result because the frailty of patients had increased.

Another key measure of performance is whether patients can return or stay at home after intermediate care.

The audit shows an 80% success for home-based services, 69% for bed, and 83% for reablement.

'Intermediate care has a crucial role'

Martin Vernon

NHS England national clinical director for older people Martin Vernon says the findings are impressive and suggests intermediate care should become a ‘key component’ of community services.

‘As all parts of the healthcare system come under increasing pressure, maintaining flow through the timely and effective delivery of care is becoming one of our biggest public service challenges to date. Intermediate care has a crucial role.’

He says NHS England will now promote the audit findings through NHS RightCare, which spreads best practice.

Deborah Sturdy, director of health and well-being at the Royal Chelsea Hospital and nursing adviser to Care England, says the time has come to fully embrace intermediate care.

‘It is common sense. Intermediate care is demonstrating better outcomes for patients and is a better use of resources than having patients delayed in hospital.’


Percentage of people who either improved or maintained their level of independence after episode of intermediate care

Dawne Garrett

Royal College of Nursing professional lead for older people and dementia care Dawne Garrett agrees, saying the audit findings show what a ‘real difference’ intermediate care can make to people’s lives.

‘It used to be that you would go into a care home and never get out, but that is changing with this focus.’

But she has a word of warning about staffing. ‘We mustn’t think that this can be done with fewer staff – a nurse and team of healthcare assistants, for example. Rehabilitation requires intensive support. You need a team of physios and occupational therapists too. It can’t be done on the cheap.’

In fact this is one of the issues flagged up by the audit, which noted there were shortages of therapists and mental health specialists in particular.

Other challenges remain. Despite the success of intermediate care the audit highlighted ‘static’ investment, with no evidence to suggest the step change in funding needed to meet demand.

What is intermediate care?

Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent there.

The services offer a link between hospitals and where people usually live and between different areas of the health and social care system – community services, hospitals, GPs and social care.

They can be delivered in a range of settings, including care homes, dedicated facilities, supported-living housing and hospitals as well as in people’s homes.

There are three main aims, which are to:

  • Avoid unnecessary hospital admission.
  • Help people be as independent as possible after a stay in hospital.
  • Prevent people from having to move into a residential home until they need to.


Total investment in intermediate care is approximately £2.8 million per 100,000 people and because of higher costs there is evidence the number of beds has actually fallen by one quarter since 2015, to 20.9 per 100,000.

There are also problems with waiting times with many services struggling to meet the two-day target, while the average waiting time for crisis care was 4.8 hours, more than twice the two-hour target.

Collaborative working

The audit also flagged up issues with how local government and the NHS worked together.

4.8 hours

Average waiting time for crisis care

(Source: NAIC 2017)

More than half of councils and CCGs had pooled budgets, but single point of access, single management structures and single assessment processes were rarer.

British Geriatrics Society nurses and allied health professionals council chair Clifford Kilgore, who works in an intermediate care service, believes the expansion of intermediate care is hampered by a ‘scepticism’ in the NHS.

‘It’s intensive so it does cost, but if you take into account you are helping frail patients recover, and that in turn prevents things like falls, the saving should be clear to see.

‘But we need to be careful how we define it. Some people see it as the equivalent of what was done in community hospitals. But it’s different. It’s not about just looking at a symptom and trying to treat that. It takes into account the whole person and finding solutions – how you manage medication when someone is living with dementia and has poor eyesight, for example.’

‘It’s a multidisciplinary team effort’

Four Seasons Health Care is best known as a major care home provider, but intermediate care is a fast-growing part of its business.

It now has 20 dedicated units in England and Northern Ireland contracted by clinical commissioning groups and local authorities.

The most recent of these opened in Leeds in December 2017. The seven-year contract will see Four Seasons run 35 intermediate care beds at one centre and 27 at another.

One is in a stand-alone intermediate care unit, while the other is based in a wing of a care home like most of its other units.

Four Seasons national director of commissioning operations Paul Hayes says nurses and carers at their units all work closely with NHS staff, including physiotherapists, occupational therapists, GPs and geriatricians.

‘It’s a multidisciplinary team effort, but nurses are the key to coordinating the care and working with the patient.

‘Where this collaborative approach is being used, it’s regarded as a success by hospital and patients alike. We are seeing patients spend ten or 12 days before they go home.’

He says the intermediate care beds are typically around £100,000 to £140,000 cheaper per year than a hospital bed, meaning a 30-bed unit could save around £4 million a year.


Further information

National Audit of Intermediate Care 2017

National Institute for Health and Care Excellence guidance on intermediate care including reablement

RCNi article

Taking risks may help regain independence. Nursing Older People

Nick Evans is a freelance health writer

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