- Royal Colleges of Physicians’ recommedations

Intermediate care has been widely welcomed as an opportunity to reinvest in assessment and rehabilitation services particularly targeted at older people.

So begins the foreword of the recently published report, Medical Aspects of Intermediate Care1. Commissioned by the Federation of Royal Colleges of Physicians of the United Kingdom to report on intermediate care and its consequences for medicine and physicians, the Working Party, chaired by David Black and including several prominent names from the British Geriatrics Society, were given a remit to review the current progress in delivering the new intermediate care services envisaged in both the NHS Plan and the National Service Framework for Older People (NSF); and to make recommendations from a medical perspective to ensure future progress in delivering effective national intermediate care type services.

Endorsed by the Edinburgh, Glasgow and London Royal Colleges of Physicians, the Working Party’s report:

• advises on the knowledge and skills required of doctors, whether in primary or secondary care, who work in intermediate care type services;
• suggests how this knowledge base can be achieved, including offering opportunites for career diversification and progression
• argues for a much greater emphasis on clinical governance in intermediate care type services and makes recommendations both at local and national level for those setting up such services.

Recommendations
The Working Party recognised that there had been a national proliferation of intermediate care type schemes and argues that these need to be formalised and organised, to ensure the future success and clinical safety of intermediate care and to meet targets set by the NHS Plan and NSF.

It recommends that:

• Intermediate care needs to be part of a defined whole-system service within any local health and care community. Appropriate, coordinated, collaborative medical input from both primary and secondary care physicians from the inception of any service is needed to achieve the medical goals of intermediate care.
• Medical input from both primary and secondary care needs to be appropriate to
  intermediate care. Participating doctors need accreditable training in:
  • clinical skills in the diagnosis and management of older people with complex needs
  • team-building skills and leadership skills
  • communication skills
  • strategic understanding and judgement, particularly in the respective contributions to care in high- and low-dependency environments
  • training and expertise in rehabilitation.
• Intermediate care may offer career opportunities for both general practitioners and consultants with appropriate skills, and may provide opportunities for career evolution for senior clinicians who have the necessary skills. Professional development required to support intermediate care services by existing doctors may require 'backfill', which requires serious consideration by the Workforce Confederations.
• All primary care organisations and commissioners of care will wish to ensure that a quality service is provided with appropriate medical input - a patient-centred service founded on the relevant evidence base*.
  *Primary care organisations do not exist in Northern Ireland or Scotland; there is no commissioning role for primary care in Scotland.
• To provide clear clinical governance, intermediate care services need to be integrated with existing services to ensure a comprehensive system of care, usually with a singledefined point of entry.
• The operation and management of intermediate care requires routine multidisciplinary groups with input from primary and secondary care as appropriate.
• In order to ensure clinical governance, improve the knowledge base, and to share experience, intermediate care schemes should provide for the routine collation of local data. Governance should include a variety of quality indicators to reflect structures, process and outcome.
• The Department of Health should, through the development of appropriate information systems, provide the opportunity for audit and research on a local and national level in order to evaluate the impact of these developments in terms of process, clinical and non-clinical outcomes.
• All schemes must have in place clinical governance arrangements involving the use of national standards, programmes of audit and systems for recording clinical incidents. Pathways of care, integrated through primary and secondary care, may facilitate the provision of care and the analysis of data.

The report goes on to set out a minimum set of standards on the medical aspects of intermediate care (see below)

The full report, priced at £7.00 is available from:

The Publications Department,
Royal College of Physicians,
11 St Andrews Place,
London NW1 4LE

e-mail: publications@rcplondon.ac.uk

Minimum standards on the medical aspects of intermediate care

1. All patients within an intermediate care service should have contemporaneous medical records.
Conformance test: When audited, all patients in the intermediate care service should have a record which begins on their entry into the service.
2. The contemporaneous medical record should be available to any doctor visiting the patient for the purpose of care when the patient is an inpatient in an intermediate care service.
Conformance test: When audited, all inpatients in the intermediate care service should have a record which begins on their entry into the service.
3. The intermediate care service should have a clear statement of purpose, which as a minimum includes whom the service is for and what it intends to do.
Conformance test: When audited, the purpose of the service, as detailed by the doctor in medical charge, should be the same as on the supporting documentation of the service.
4. Any intermediate care service should be able to describe the components of the
service.
5. The components of the intermediate care service should be defensible by evidence from research or from the standpoint of a reasonable body of medical opinion.
Conformance test: When audited and questioned, the doctor(s) involved in
the service should be able to defend the existing components of the service, or demonstrate that they have suggested better ways of providing the service.
6. The doctor who is medically accountable for the care in the service should be known to all the patients and staff.
Conformance test: When audited, any mentally competent patient or member of staff should be able to name the doctor medically accountable for the service.
7. The designated clinician who leads and is accountable for the intermediate care service should be known to all patients and staff.
Conformance test: When audited, any mentally competent patient or member of staff should be able to name the person who leads the intermediate care service.
8. The responsibilities for routine medical care of the patients in an intermediate care service should be made explicit and incorporated into a job plan if it involves a consultant physician.
Conformance test: When audited, any doctor who is involved in the intermediate care service should be able to produce a job description of their role, and if the doctor is a
consultant physician a supporting job plan should be available.
9. The responsibilities for out-of-hours medical care of the patients in an intermediate care service should be made explicit, and incorporated into a job plan if it involves a consultant physician.
Conformance test: When audited, the out-of-hours medical care should be set out clearly in the operational plan of the unit, and the unit should be able to demonstrate that it works well in practice.
10. Complaints about medical care should be investigated appropriately and remedial action taken. The doctor should play a full and active role.
Conformance test: When audited, all complaints about medical care should be available, and management should be able to show a thorough investigation, medical participation and responsive changes to the service and/or individuals within it.
11. The intermediate care service should be able to demonstrate that its outcomes are at least as good as the service it replaces.
Conformance test: When audited, the deaths, transfers and institutional care rates from the intermediate care facility should be better than the service it replaces, or existing comparative services.
12. Inpatient services should have an explicit policy with evidence of implementation on cardiopulmonary resuscitation (CPR).
Conformance test: When audited, case notes for inpatients should clearly demonstrate the decisions taken with patients with regard to CPR.