The problem
In many systems, intermediate care delivered by health and social care services are still organised and delivered separately, creating fragmented care with gaps, overlaps, and confusion. Operational models for Pathway 1 show considerable variation, with some areas running parallel social care and community health approaches, while others have merged into a single offer.
Integration can take multiple forms: pathway-based integration, aligned service approaches, or deeper functional integration within new structures. Rather than attempting to impose a uniform model across the country, the aim is to capitalise on the opportunities that collaborative working provides.
Voices from stakeholders
“We have a Head of Intermediate care post, jointly funded by health and the local authority, as a single point of escalation and oversight”.
“We joined up reablement, home first, crisis support, and admission avoidance. Whether it’s step up or step down, people just come into short-term support”.
Actions
D1. Map and streamline existing teams into a coherent, integrated offer with strengthened care co-ordination
| Step | Action |
| Step 1 | Consider integrated service models appropriate to local context and existing teams available: pathway-based, aligned services, or deeper functional integration of existing teams. |
| Step 2 | Invest in shared training, shared IT systems, information governance infrastructure and integrated management structures to break down silos. |
| Step 3 | Agree co-ordination arrangements appropriate to local context — whether through transfer of care hubs, single points of access, or other integrated approaches at place level. |
| Step 4 | Establish clear, standardised pathways for both step-up and step-down, with defined roles and responsibilities across teams. |
Productivity impact
More integrated working delivers both efficiency gains (through reduced duplication and handoffs) and outcomes gains (through more co-ordinated, person-centred care).
[Link to case study]