Intermediate Care (IC) is now an established part of services for older people and has been given added impetus by the National Service Framework for Older People.¹

The Joint Committee on Higher Medical Training (JCHMT) has recognised this and is introducing mandatory training in IC. It has set the objectives, subject matter and methods of assessment, but has not fleshed out how this is to be delivered². It seems likely that training programmes will vary to reflect local provision of services.

Training sessions in community geriatrics, recently incorporating IC, have been available in Cambridge (provided by Tony Luxton) for interested specialist registrars (SpRs) for six years. Building on this experience, we suggest the following broad structure which we have already submitted to the Programme Director of the East Anglia Deanery with the intention of stimulating the development of local programmes for SpRs. We recognise that training programmes in geriatric medicine already leave little or no room for the introduction of additional components. Therefore local agreement must be reached to create time for training in IC. We suggest a half or one day per week over three months.

We suggest that programmes should begin with tutorials introducing IC and community care of older people, touching on the wider context of the organisation of health and social services, the independent sector, and related subjects such as capacity. The tutorials should be up to one hour in duration, on a fortnightly schedule. Tutorials will be supplemented by a range of practical experience including visits to intermediate care facilities, reflecting local provision. In Cambridge, IC can be provided in a person’s own home, a residential home, a nurse-led unit and in a community hospital. Whilst visits can give a general perception of services, more direct involvement will consolidate the training.

The SpR will not only have training in day to day patient care in a community hospital but will work directly with the other team members. Locally the trainee (Joseph Yikona) will join the rapid response teams, home visits with the occupational and physiotherapists and social workers. This participation will help the SpR learn about the team structure, how it functions in practice and combats problems. The combination of tutorials and practical experience will develop skills in the appropriate use of IC and community services, and will complement the knowledge gained from working in day hospitals.

The SpR will follow a cohort of patients before, during the IC episode, and after discharge. The SpR will take direct supervised responsibility for planning the appropriate level of service by seeing prospective patients before agreeing admission to IC, following progress and liaising with the patient’s general practitioner, and will visit the patient after transfer home. The SpR will use the observations and experience gained from this possibly to write up a project to demonstrate knowledge about IC, the advantages and disadvantages of the local service, and to provide suggestions for changes to improve the service. A presentation of this project work to members of the multi-disciplinary team followed by open discussions should provide the SpR with considered insight into his/her performance.

We believe that our suggestions provide a practical way of teaching intermediate care and providing a perspective on community services.

Joseph Yikona
Specialist Registrar
joyikona@aol.com
Tony Luxton
Consultant Community Geriatrician
tony.luxton@cambcity@pct.nhs.uk

References:

1. Department of Health. National Service Framework for Older People. London. 2001
2. Joint Committee on Higher Medical Training. Update : Training in Geriatric Medicine. London. January 2004