Health and Social Care in the Community (2008) 16(6), 629–637 doi: 10.1111/j.1365-2524.2008.00788.

Challenges, benefits and weaknesses of intermediate care: results from five UK

Blackwell Publishing Ltd

case study sites

Emma Regen BA MA1, Graham Martin MA(Oxon) MSc2, Jon Glasby BA PhD3, Graham Hewitt BA PGDip4,
Susan Nancarrow PhD5 and Hilda Parker BA BA(Hons) CQSW6
1
Leicester Nuffield Research Unit, Department of Health Sciences, University of Leicester, 22–28 Princess Road West,
Leicester LE1 6TP, 2Institute for Science and Society, University of Nottingham, University Park, Nottingham NG7 2RD,
3
Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham B15
2RT, 4Faculty of Medicine and Biological Sciences, University of Leicester, Maurice Shock Building, University Road,
Leicester LE1 7RH, 5Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam
University, 32 Collegiate Crescent, Sheffield S10 2DP, 6Division of Primary Care, University of Nottingham, Graduate Medical
School, Derby City General Hospital, Uttoxeter Road, Derby DE22 3DT, UK

Correspondence
Emma Regen
Leicester Nuffield Research Unit,
Department of Health Sciences,
University of Leicester,
22–28 Princess Road West,
Leicester LE1 6TP, UK
E-mail: elr14@le.ac.uk
Abstract
The authors explore the views of practitioners and managers on the
implementation of intermediate care for elderly people across England,
including their perceptions of the challenges involved in its implementation,
and their assessment of the main benefits and weaknesses of provision.
Qualitative data were collected in five case study sites (English primary care
trusts) via semistructured interviews (n = 61) and focus group discussions
(n = 21) during 2003 to 2004. Interviewees included senior managers,
intermediate care service managers, clinicians and health and social care
staff involved in the delivery of intermediate care. The data were analysed
thematically using an approach based on the ‘framework’ method.
Workforce and funding shortages, poor joint working between health and
social care agencies and lack of support/involvement on the part of the
medical profession were identified as the main challenges to developing
intermediate care. The perceived benefits of intermediate care for service-users
included flexibility, patient centredness and the promotion of independence.
The ‘home-like’ environment in which services were delivered was contrasted
favourably with hospitals. Multidisciplinary teamworking and opportunities
for role flexibility were identified as key benefits by staff. Insufficient
capacity, problems of access and awareness at the interface between
intermediate care and ‘mainstream’ services combined with poor co-ordination
between intermediate care services emerged as the main weaknesses in
current provision. Despite reported benefits for service-users and staff, the
study indicates that intermediate care does not appear to be achieving its full
potential for alleviating pressure within health and social care systems. The
strengthening of capacity and workforce, improvements to whole systems
working and the promotion of intermediate care among doctors and other
referrers were identified as key future priorities.

Keywords: elderly people, intermediate care, qualitative study

Accepted for publication 25 February 2008

forming a key component of the National Service

Introduction
Framework for Older People (Department of Health
First articulated as a formal policy in the National 2001a), the implementation of intermediate care has
Health Service Plan (Department of Health 2000a) and been a policy imperative for all those involved in the

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E. Regen et al.

Box 1 The definition of intermediate care

According to Health Service Circular 2001/001 (Department of Health 2001b), intermediate care services should meet all of the
following criteria:
• They are targeted at people who would otherwise face unnecessary prolonged hospital stays, or inappropriate admission to acute
in-patient care, long-term residential care or continuing National Health Service inpatient care.
• They are provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active
therapy, treatment or opportunity for recovery.
• They have a planned outcome of maximizing independence and typically enabling patients/users to resume living at home.
• They are time limited, normally no longer than 6 weeks and frequently as little as 1–2 weeks or less.
• They involve cross-professional working, with a single assessment framework, single professional records and shared protocols.

commissioning and provision of care for elderly people
in England since 2000. In promoting the development of
a new range of intermediate care services to ‘bridge the
gap’ between hospital and primary and community
care (Department of Health 2000a), the government was
largely responding to problems with the free flow of
patients through and out of acute hospital care as
highlighted by the Audit Commission (1997) and the
National Beds Inquiry (Department of Health 2000b).
Accordingly, while the precise nature and definition of
intermediate care have remained a matter of considerable
debate (Steiner 2001, Melis et al. 2004), in general terms
it can be said to comprise services, primarily catering
for elderly people, which seek to prevent unnecessary
hospital admissions, facilitate earlier discharges and avoid
premature admissions to long-term care (Department
of Health 2001b). Implementation has been underpinned
by several policy statements which have set out targets
relating to intermediate care (Department of Health
2000a) as well as a working definition (Box 1).
Intermediate care is not a new idea. A range of
schemes has proliferated since the early 1990s, and some
evidence for the effectiveness of particular interventions
has been available for a while (Wilson et al. 1999, Parker
et al. 2000, Steiner et al. 2001, Young 2002). Parker et al.’s
(2000) systematic review found that with the notable
exception of stroke unit care, the evidence for effective-
ness of these services suggested at best clinical equiva-
lence with conventional inpatient alternatives. The wider
literature provides some evidence for interventions
similar to those grouped under ‘intermediate care’ in
the British context. A review of intermediate care in
nursing-led inpatient units concluded that overall there
is no adverse effect on mortality, and that discharge to
institutional care may be reduced and functional status
improved with a reduction in early readmission (Griffiths
et al. 2004). In the United Kingdom (in contrast to the
United States), costs are higher. A review of care-home
versus hospital and own-home environments for re-
habilitation of elderly people found that there is insufficient
evidence to draw conclusions about the various settings
for rehabilitation for elderly people (Ward et al. 2003). In
a study examining hospital at home and comparing it to
hospital inpatient care, the authors concluded that early
discharge in certain patient groups may reduce pressure
on acute beds (Shepperd 2001), but that there was in-
sufficient evidence of economic benefit.
The government’s decision to pursue a formal policy
of intermediate care and roll-out services nationally,
however, drew criticism from a range of quarters. Some
spoke in terms of ‘discriminatory ageism’, expressing
concerns that elderly people could be inappropriately
diverted away from medical services in a bid to alleviate
pressures in acute care (Ebrahim 2001, MacMahon 2001,
British Geriatrics Society & Age Concern 2002). Others
highlighted what they regarded as a paucity of evidence
to support the widespread development of intermediate
care (Grimley Evans & Tallis 2001, Pencheon 2002). In
this context, the Department of Health (Policy Research
Programme) commissioned a £1.2 million programme
of evaluation of intermediate care, funding three major
studies which have recently reported their findings (see
Green et al. 2005, Martin et al. 2007, Moore et al. 2007).
The data reported in this and a follow-up paper are
based upon the case study component of one part of this
evaluation programme: a multi-method national evalu-
ation of the costs and outcomes of intermediate care for
elderly people. This first paper presents the findings of
qualitative research which examined the views of
practitioners and managers on the challenges, benefits
and weaknesses associated with the implementation of
intermediate care. The second paper draws upon quan-
titative data in order to provide an economic analysis of
the costs and health outcomes of intermediate care.
Subjects and methods
Case study approach
Qualitative and quantitative data collection was con-
ducted in five case study sites (see Table 1) in England
between January 2003 and November 2004. The methods
used for the collection and analysis of quantitative data
in the case study sites are described in the follow-up
paper. Ethical approval was obtained from the Trent
Multi-centre Research Ethics Committee.

630 © 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd
 Challenges, benefits and weaknesses of intermediate care

Table 1 Summary characteristics of the case study sites

Description of Description of
health and social intermediate care Types of intermediate
Site Population range Nature of area care system system care services provided

A 250 000–300 000 Urban
B 200 000–250 000 Urban
C 150 000–200 000 Urban/Semi-rural One of three PCTs
D 150 000–200 000 Rural/Semi-rural One of three PCTs
E 200 000–250 000 Urban and rural
City-wide PCT,
coterminous
with social services
One of four PCTs
covering large city;
social services
city-wide
covering county; working
alongside county-wide
social services
covering county;
working alongside
county-wide
social services
One of three PCTs
covering county;
working alongside
county-wide
social services
No single point of Rapid response/
access for IC; community teams
services operating Supported discharge
as a managed teams (with domiciliary
network care)
Residential IC: nurse-led
unit in acute hospital;
community rehabilitation
beds; sheltered housing facility
Single point of access Rapid response/community team
for IC with professionally Residential IC: IC unit and beds
qualified referral taker in independent sector care home
Single point of access Rapid response rehabilitation teams
for IC with non-qualified Residential IC: purpose-built
referral taker IC unit; sheltered housing facility
Two points of access Rapid response
for IC (geographically Rehabilitation domiciliary care
based) with non-qualified Rehabilitation units (day centre,
referral takers day hospital, community hospital)
Residential IC: beds in
independent sector
residential home; sheltered
housing facility
Single point of access Community rehabilitation teams
for IC with non-qualified Day hospital (rapid assessment
referral taker and rehabilitation)
Residential IC: beds in community
facility; beds in independent
residential home; sheltered
housing facility

Five primary care trusts were selected as case studies
to represent ‘whole systems’ (an area with a specific
geographical boundary) of intermediate care. By study-
ing whole systems as opposed to individual service
models, we aimed to achieve a more detailed under-
standing of the implementation of intermediate care
and its impact upon system-level costs and outcomes.
We selected the case study primary care trusts accord-
ing to the following criteria: (1) a range of intermediate
care service operational for at least 2–3 years; (2) reason-
able throughput into the intermediate care system (at
least 1000 cases per annum); (3) a mix of urban and rural
sites; (4) senior management support for the collection
of routine data by the services themselves; and (5) clinical
and managerial support for participation in the evaluation.
Most sites were operating in a context whereby a single
social services department (county- or city-wide) was
attempting to work alongside several locality-based
PCTs (sites B, C, D, E). The exception was site A where
the city-wide PCT was coterminous with social services.
In terms of the organization of IC, all of the case study
sites were attempting to bring (on the whole) pre-
existing separate services into a wider network of inter-
mediate care provision which would be integrated with
‘mainstream’ care in line with government guidance
(Department of Health 2002). In four of the sites (B, C, D,
E), a key mechanism for improving links between inter-
mediate and mainstream care was the establishment of
a single point of access for referrals to intermediate care.
Site A had developed an alternative approach. Here,
there was no single point of access. Instead, intermediate
care operated as a ‘managed network’ which sought to
bring the range of services into a single operating system
via closer links between services, agreed pathways of
care and clearer access points.
Data collection
We conducted semistructured interviews with 36
individuals involved in the strategic development of

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E. Regen et al.

Table 2 Summary of interviews and focus groups by site and role

Interviews
Strategic level: senior managers
Site and medical staff relating to IC
Focus groups: with practitioners
Service level: lead professionals (nurses, allied health professionals,
and managers for individual care assistants) grouped by
IC services IC service Total

A 11 10 7 28
B 6 4 4 14
C 6 5 1 12
D 6 5 6 17
E 7 1 3 11
Total 36 25 21 82

intermediate care across the five case study sites. These
interviewees were recruited with the help of intermediate
care co-ordinators, and included senior managers and
clinicians within primary care trusts, social services
and the acute sector. In addition, 25 interviews were
conducted with intermediate care service managers, and
21 focus groups were held with staff directly involved
in the provision of services (Table 2). Focus groups
comprised between two and eight participants, and
included therapists, nurses, social workers and support
workers from single teams. Interviews attempted to
gain an in-depth understanding of the challenges
faced in strategically implementing intermediate care,
while focus groups provided an opportunity for more
collective discussion within a team responsible for
intermediate care delivery on the ground.
In common with other applied qualitative policy
research, we developed a topic guide with reference to
our research questions and the wider literature (Pope
et al. 2000). As well as describing their own roles and the
nature/organization of service provision, participants
were invited to reflect upon factors which had shaped
the development of intermediate care and to provide
an assessment of its strengths and weaknesses. During
the interviews, which typically lasted 60–90 minutes,
participants were also able to raise other issues of
importance to them.
Data analysis
All interviews and focus group discussions were
recorded and transcribed. Qualitative data analysis
was informed by the ‘framework’ approach which was
developed specifically for policy-relevant research
(Ritchie & Spencer 1994). Data from each case study site
were analysed separately. First, we developed a coding
frame which provided a detailed index of the data
typically comprising 30–35 substantive categories, on
the basis of data from site A, but with minor alterations
for other sites where other categories were more pro-
minent. The coding frame was then applied to the data via
the annotation of interview transcripts. Data were
subsequently rearranged (via cutting and pasting) into
the appropriate part of the substantive coding frame to
which they related. Finally, analytic themes (generaliza-
tions drawn from the data) and concepts (theoretical
abstractions around cause and mechanism) were devel-
oped for each of the categories via a process of mapping
and interpretation (Ritchie & Spencer 1994), and the
data from each site were amalgamated and synthesised.
Analysis was performed by small teams of researchers
who analysed data independently, then met regularly
to discuss and validate the themes and concepts gener-
ated. Disconfirming cases were included and themes
were modified to take account of these. Results were
fed back both to research participants and to funders,
enabling validation of the analysis and findings. The
quotations included in Results serve to illustrate the key
emergent themes in terms of the challenges in develop-
ing intermediate care, its benefits and its weaknesses.
Results
Developing intermediate care – challenges
Difficulties relating to the recruitment and retention of
both qualified and non-qualified staff were identified as
the most significant challenges to the implementation of
intermediate care in all case study sites. Insufficient
funding and problems attracting staff to posts were
highlighted as the main causes. The potential for profes-
sional isolation within small community-based teams
and a lack of awareness of intermediate care were iden-
tified as deterrents by professional staff. For support
staff, low wages and long, unsociable hours were per-
ceived as particular barriers to recruitment.

632 © 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd

One of the biggest things that has been the problem is the fact
that there has been a lack of a capacity and by that I mean we
have not got the staff levels to offer the service we would want
to. It is very difficult to get hold of rehab assistants . . . through
one thing and another, be it low money or bad shifts, people
don’t necessarily want to do that. (E1)
In addition to perceived funding shortages (exacer-
bated by the fact that central government did not
require designated funding to be used for intermediate
care only), the short-term, non-recurrent nature of some
funding for intermediate care was also seen as problematic.
Interviewees reported that it was difficult to contemplate
service development in the medium to long term with
many staff appointed on short-term contracts and
uncertainty over future additional funding. Moreover,
wider financial pressures in health and social care
systems meant that the primary/community services
required to underpin intermediate care were also
frequently under-funded.
The referrals are increasing in the community to keep people
at home, but the resources haven’t increased in keeping with
them; there isn’t the money, there isn’t the home care, there
aren’t the therapists. We’re just running all the time, running.
(D4)
A lack of effective joint working between health and
social care agencies was highlighted as a major impediment
to the implementation of intermediate care in all case
study sites. At the strategic level, competing organiza-
tional visions for intermediate care and the existence of
separate (as opposed to joint or pooled) budgets had
militated against a coherent, ‘whole systems’ approach
to service development (Department of Health 2002).
In sites C, D and E, competing organizational visions
for intermediate care and disagreements over which
agency ought to be leading strategic developments were
revealed, in stark contrast to the government’s desire
for a ‘whole systems’ approach:
It still feels to me like there’s quite a bit of potential in-fighting
between social services and [the] PCT about who owns it,
who’s taking the initiative. Maybe that’s at certain levels ...
but it shouldn’t be like that, it’s an integrated service, you
can’t talk about owning it, it can’t be like that. (E5)
Even in areas where joint working had been relatively
positive (notably in site A), the desire of organizations
to retain control of their own budgets had placed
limitations upon partnership working and the develop-
ment of intermediate care:
There has been very good collaborative work between agencies
for a number of years ... but one of the stopping points, if you
like, or the barriers to taking that work forward, is different
financial budgets, for example. Everybody is all for joint
working and collaboration until you start asking people to
© 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd
Challenges, benefits and weaknesses of intermediate care
give over ... money and that is a constant tension and I think
perhaps has stood in the way of really making good progress
and having a more flexible model. (A15)
At the operational level, different employment and
health and safety policies held by health and social
care agencies combined with incompatible information
technology and data collection systems to present
significant challenges to ‘frontline’ staff.
A perceived lack of support and involvement on the
part of the medical profession was identified as a barrier
to the development and use of intermediate care services
by non-medical interviewees in three case study sites.
Doubts about intermediate care were attributed to
concerns about the lack of evidence for its effectiveness
and fears that the aim of keeping elderly people out of
hospital was potentially discriminatory.
The more senior members ... of the medical profession could
remember days when older people had been warehoused, so
to speak, in environments outside hospital because they were
not considered worthy of hospital admission and they didn’t
want to go back to those days where people were being basically
cared for and denied proper assessment and treatment. (B1)
At the same time, however, interviewees in four of
the five case study sites revealed that acute sector
clinicians had felt excluded from the development and
provision of intermediate care to some degree. Reluctance
on the part of some general practitioners (GPs) to
provide medical cover for intermediate care facilities
was explained in terms of heavy workloads and a lack
of incentives. This was a particular challenge in site B
which had a high proportion of single-handed GPs and
a history of poor GP engagement in service developments
generally.
Consultant geriatricians were, in some instances,
concerned about the introduction of intermediate care
because they felt the initiative was launched in the
absence of good evidence.
If I need to convince my colleagues, then I think I would need
robust evidence. Nowadays, everything is evidence based
and unless we develop some evidence and say this is what
is happening, it’s going to be very difficult to convince the
sceptical. (B2)
One consultant, who supported intermediate care,
reported that his colleagues were suspicious of his
motivations for supporting the initiative at all. Consultants
also expressed concern that intermediate care could
discriminate against elderly people because of its specific
aim to reduce their use of hospital services.
The introduction of intermediate care presented
opportunities for the expansion of nurse and allied
health practitioner roles, particularly into leadership
positions, with the added potential benefit of saving
633
E. Regen et al.
costs. For some, this was translated into a perception
that doctors were not needed in intermediate care
services. Indeed, one site (B) had no formal medical
involvement in intermediate care, which was attributed
to GP reluctance to be involved.
However, consultants felt that lack of medical input
could be a false economy because unmet medical needs
in patients would result in longer stays or re-admissions.
Additionally, they saw medical input as necessary to
ensure that intermediate care services were ‘safe’. A
potential advantage of consultant input was in smooth-
ing the transition between hospital and intermediate
care services, while increasing the credibility of the
intermediate care services with other hospital staff:
It smoothes the working between the acute hospital and the
intermediate care unit, and it also means that I can, if you like,
re-assure colleagues that it’s a proper unit, there’s proper
medical support as well as the multidisciplinary care and my
working across the two units hopefully re-assures people that
communication is good, the pathways of referral are recognised
and so on. (B1)
Benefits of intermediate care
There was a strong perception among interviewees in
all case study sites that the main strength of intermediate
care was the range of benefits it offered to service-users.
These were described both in terms of experience and
outcomes, particularly when compared with more
‘traditional’ forms of care. In contrast to care provided
on a hospital ward, intermediate care was regarded as
being responsive, patient centred, flexible and holistic.
They get like a one-to-one service. If they’re in a hospital base,
you get your healthcare assistants with however, many other
patients there are in a ward. They get individual attention
whether it’s from us, whether it’s from their own district nurse
in their own home and they thrive on it. (A24)
Interviewees placed significant emphasis upon the
‘home-like environment’ in which intermediate care
services were delivered. Be it home or a residential
environment, the intermediate care setting was generally
regarded as being beneficial, particularly in achieving
outcomes such as independence and increased confi-
dence. Again, these benefits were described in the
context of the dependency perceived to follow a stay in
hospital.
By delivering services in an individual’s own home,
the ‘upheaval’ and potential for confusion in response
to unfamiliar hospital surroundings could be avoided:
The elderly don’t like too much change and too much
upheaval. [...] Taking them out of those surroundings can
cause more confusion and dilemma for them, which is not
helpful in their rehabilitation. (C6)
634 © 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd
Moreover, service-users could retain much-valued
support networks and social activities seen as essential
to their rehabilitation. In addition, some interviewees
suggested that as a result of ‘being on their own territory’,
users and their relatives played a more active role in
rehabilitation planning and goal setting.
The establishment of effective multidisciplinary
teamworking was reported as a strength of many of the
intermediate care services and was regarded as having
benefits for staff as well as users. Interviewees spoke
positively of the support they received from fellow
team members and of being able to access expertise
from a range of professionals. While recognizing their
limitations, many practitioners welcomed increased
opportunities for role flexibility in the intermediate care
setting as they undertook tasks which would normally
be performed by others.
We’re multidisciplinary but we’re also very interdisciplinary.
But having said that we know our boundaries so as a nurse
going out to see a patient, I would carry out my nursing tasks
but I wouldn’t just go out there and do my nursing tasks,
which would happen on a ward. There wouldn’t be such an
overlap [on a ward] as there is within the team ... so if they’re
having to carry out an exercise programme then it would
be expected of me as a nurse to go through that exercise
programme with them on behalf of the physio. (A5)
Staff also spoke of the job satisfaction they had
gained from being involved in the delivery of inter-
mediate care. This appeared to be inextricably linked with
the goal of restoring or maintaining the independence
of service-users.
Weaknesses of intermediate care
There was a view in all case study sites that intermediate
care services did not have the capacity to fulfil their
potential for alleviating pressures within health and
social care systems. Interviewees drew attention to
limitations in terms of numbers of beds and places,
staffing levels and operating hours. While these prob-
lems were frequently attributed to insufficient funding
for intermediate care, difficulties in recruiting and
retaining staff were also highlighted. For sites C, D and
E operating within rural or semi-rural areas, staff
recruitment had been particularly challenging and yet
was all the more crucial when large geographical areas
needed to be covered by intermediate care teams:
We need more staff so that for certain areas or patches we can
have local staff to deal with it rather than ripping between
[Northford] which is up the road that way 60 miles down to
[Southbridge]. It is not cost effective. (D3)
A particular problem in three of the case study sites
was a shortage of care workers and rehabilitation assistants.

This had led to an inability to cater for potential service-
users even when all criteria were met and therapist
input was available. In addition, lack of mainstream
home care in these sites sometimes meant that patients
who could otherwise receive intermediate care in their
own homes could not be left safely overnight or receive
assistance with daily activities. Potential service-users
were sometimes admitted to hospital as a result. The
inability of many intermediate care services to respond
to referrals or to provide care out-of-hours was identi-
fied as a particular problem for GPs who sometimes had
no option but to admit patients to hospital.
Lack of knowledge about intermediate care services
and difficulties in accessing them presented barriers to
their use within all case study sites. This was a particu-
lar concern in site A where the absence of a single point
of access for intermediate care was regarded as a signi-
ficant barrier to its use by GPs. In addition, the eligibility
criteria for services were often perceived as too narrow
by referrers. As a result, intermediate care was sometimes
seen as being rather ‘elitist’, and accusations of ‘cherry-
picking’ were not uncommon. Recurring problems admit-
ting patients to intermediate care meant that practitioners
often reverted to more traditional forms of care.
So the experience on the ground, when I talk to people in the
hospital and say ... ‘This looks like intermediate care to me,
did you phone last night? You know, we’ve been telling you
about it’, he said, ‘Oh that was no good, I phoned and they
weren’t interested’, or ‘They said they didn’t have any space.’
‘I’m losing faith in intermediate care’, ‘I can’t see the point’:
I get comments like that all the time. (E5)
A small number of interviewees felt that more could
be done to address issues of perceived risk in relation to
intermediate care as part of developing confidence in
such services.
The big cultural thing we found in particular about the inter-
mediate care beds is hospital staff being prepared to take the
risk and discharge somebody to something new that is rela-
tively 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 con-
fidence to do it again. (D16)
Alongside under-use, the other main tension between
intermediate and secondary care services was inappro-
priate use of intermediate care. Highlighted as an issue
in all case study sites, many interviewees were con-
cerned that intermediate care was becoming dominated
by acute care agenda that focused more upon freeing up
beds than it did on working at the pace of the individual
elderly person and finding the right environment to
maximise their recovery.
A lack of integration between individual intermediate
care services was highlighted as another area of weakness
© 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd
Challenges, benefits and weaknesses of intermediate care
in four case study sites. This manifested itself in problems
relating to access, care pathways and resistance to
flexible working, for example across services. Lack of
co-ordination and integration between intermediate
care services was regarded as a legacy of the ad-hoc,
‘bottom-up’ way in which many services had evolved.
Sites C, D and E faced the additional challenge of
having to operate across large rural areas which also
presented a practical barrier to closer collaboration
between services. Knowledge about other intermediate
care services and their eligibility criteria was variable in
most sites including in site A where this, combined with
the lack of a single point of access, raised particular concerns
about how the smooth flow of service-users through the
appropriate parts of the system could be ensured.
In terms of the range of provision, some interviewees
reported that elderly people with mental health problems
were poorly served by existing services because of a lack
of specialist mental health input in intermediate care.
Others saw the national and local focus upon early sup-
ported discharge and beds-based services as misguided,
and argued for more proactive services in the form of admis-
sion avoidance and community-based intermediate care.
Discussion
Our findings reveal workforce and funding shortages,
poor joint working and scepticism/disengagement on
the part of the medical profession as the main challenges
to the development of intermediate care. The main
perceived benefits of intermediate care for service-users
were described in terms of patient centredness, flexibility
and the promotion of independence. Staff highlighted
the opportunities associated with working in multi-
disciplinary/interdisciplinary environments as key benefits.
Insufficient capacity, problems of access and awareness
at the interface between intermediate care and ‘mainstream’
services combined with poor co-ordination between
intermediate care services were identified as the main
weaknesses in provision.
Limitations of the study
As our main contacts in the case study sites, intermediate
care co-ordinators were largely responsible for identifying
potential interviewees on our behalf. Despite mak-
ing it clear that we wished to gain access to a range of
perspectives, the majority of those selected for inter-
view were generally directly involved in either the man-
agement or delivery of intermediate care, and hence
potentially more favourable in their views. It should be
noted, however, that interviewees did not refrain from
describing weaknesses regarding the implementation
of intermediate care.
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The fact that we did not interview service-users
about their experiences of intermediate care could be
seen as another weakness in our approach. It should be
pointed out, however, that a patient satisfaction survey
was conducted for all intermediate care services across
the five case study sites. This revealed relatively high
levels of satisfaction with intermediate care and as such
lends support to the perceptions of practitioners and
managers who identified significant benefits for users
(Wilson et al. 2006).
Relevance to the existing literature
Our study of whole systems of intermediate care sup-
ports many of the findings reported in evaluations of
particular intermediate care schemes. The perceived
benefits for patients, usually linked to the ‘home-like’
care environment, have been described previously
(Wilson et al. 2002, Roe et al. 2003, Martin et al. 2005).
Likewise, disengagement, lack of awareness and doubts
about intermediate care on the part of GPs and hospital
doctors have also been highlighted (MacMahon 2001,
Wilson & Parker 2003). A prominent finding from our
work was the extent to which workforce shortages and
insufficient capacity within intermediate care were
perceived to have hindered its development. Again, this
has been highlighted in previous research (Nancarrow
2004). Our findings support and reinforce the view that
intermediate care needs to form part of a continuum of
services linking primary, community, secondary and
social care provision if it is to achieve its potential
(Department of Health 2002, Asthana & Halliday 2003).
Implications for policy and practice
Workforce and capacity shortages have reportedly lim-
ited the ability of intermediate care services to respond
to and accept referrals. Given that interviewees described
both capacity pressures and a lack of referrals from
mainstream services, it would appear that capacity needs
to be expanded significantly if intermediate care is to
deliver its objectives and meet potential demand. That
being so, the ability to secure access to long-term
funding and to attract both qualified and non-qualified
staff to intermediate care would appear to be important
priorities at the local level. Concerns about capacity,
however, need to be understood in the context of the
quantitative data presented in the follow-up paper.
Findings presented in this suggest that a significant
proportion of intermediate care referrals represent an
additional, rather than a substitute service.
Fragmentation and poor integration with other
services have reportedly compromised the extent to
which intermediate care can alleviate pressure within
636 © 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd
health and social care systems. We identified improved
joint working between health and social services; better
co-ordination between intermediate care services; and
increased integration between intermediate, primary
and secondary care as the key areas for development in
fostering the whole systems approach advocated in
government policy (Department of Health 2002, Asthana
& Halliday 2003).
The need to promote awareness about and confi-
dence in intermediate care among doctors and other
potential referrers is another priority. The collection
and dissemination of robust evidence regarding the
effectiveness of intermediate care are crucial to this
process. There would appear to be considerable scope
for GPs to be more directly involved in the delivery of
intermediate care services, particularly those aimed at
preventing unnecessary hospital admissions. It is
recognised that such involvement would be contingent
upon appropriate incentives and support being made
available (Wilson & Parker 2003).
Finally, our research has implications in terms of the
future direction of intermediate care policy and practice.
We identified calls for a shift in emphasis away from
beds towards non-residential forms of intermediate
care and admission avoidance schemes. This appeared
to reflect a desire for services to become more proactive
in the interests of effectiveness and efficiency. Again,
these views need to be considered alongside findings
reported in the follow-up paper, which examines the
costs and outcomes associated with particular types of
intermediate care.
Acknowledgements
We thank the intermediate care co-ordinators and the
staff who participated in focus groups and interviews
in the five case study sites. Thanks also go to Teresa
Faulkner and Sandy Williams who provided secretarial
support to the project. We are also grateful to the
Department of Health and the Medical Research Council
who funded the study as part of the Health Policy
Research Programme, and to three anonymous referees
for their helpful comments.
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