The problem
Intermediate care is not a single service; it is a system of services delivered in people’s homes and bedded care settings, often by multiple providers using different case management and operational systems. This fragmentation makes it extremely difficult to establish operational grip, particularly in the context of demand and financial pressures.
But without operational grip, improving the effectiveness of services is impossible. The starting point is clarity: knowing what services exist, who is responsible for them, what demand is expected and whether the service capacity is available. This is capacity to meet both the numbers of people and their acuity/complexity.
Voices from stakeholders
“We don’t have a shared plan – we rely on working relationships to get things done”
“On the ground we work really well together and have a ‘can do’ attitude”
“What really struck me is that when we mapped it out, it’s not a holistic or continuous service. There’s a whole range of things that are commissioned separately”
Actions
A1. Map existing intermediate care services and identify responsible owners
| Step | Action |
| Step 1 | Convene health and social care commissioners and providers in a series of workshops to build a shared view of all services. |
| Step 2 | Document for each service: provider(s), service description, hours of operation, eligibility criteria, commissioned and actual capacity (including intensity), workforce, average length of episode throughput, outcomes evidence, responsible manager, and funding by partner, definitions of key terms used in different organisations related to intermediate care. |
| Step 3 | Identify gaps, overlaps, and areas for improvement — this creates the baseline for continuous improvement processes. |
| Step 4 | Consolidate any ‘quick wins’ which have emerged from this process for immediate action. |
A2. Establish useful, accurate and timely operational reporting
| Step | Action |
| Step 1 | Build on the A1 baseline to establish a consistent approach to capacity reporting (e.g. reablement hours, therapy-at-home, Pathway 2 standard intermediate care beds; intermediate care beds for more complex needs, people with confusion/delirium/dementia, and people who are homeless. |
| Step 2 | Agree co-ordination through a single point in the system. A care transfer hub, single point of access, or other co-ordination arrangement may be appropriate depending on local context. |
| Step 3 | Collaborate on implementing one single list of all people waiting for or actively being supported in intermediate care, rather than working from multiple competing lists. This should include admission dates and estimated dates of transition, enabling real-time prioritisation. |
| Step 4 | Empower the co-ordination point to deploy and allocate resources, matching capacity to need in real time. |
| Step 5 | Establish a regular proactive cycle of capacity reporting, circulated to and reviewed by both operational managers and system executive leaders. |
A3. Regularly review operational data
| Step | Action |
| Step 1 | Establish regular circulation of intermediate care operational reporting alongside acute and urgent care performance reporting — raising the profile of intermediate care in system discussions. |
| Step 2 | Commission a working group to develop a shared dashboard providing a single version of the truth. Systems can improve operational grip without real-time data initially, building towards this over time. |
| Step 3 | Use data reviews to identify improvement opportunities and ensure consistency across areas. |
A4. Establish a rigorous approach to reviewing goals and stepping people down
| Step | Action |
| Step 1 | Conduct an initial assessment within 24 hours of service start to establish goals with the individual. |
| Step 2 | Initiate planning of arrangements for the individual to exit the service, directly involving the person and any carers. |
| Step 3 | Communicate goals to all professionals involved in supporting the person through a shared records system |
| Step 4 | Ensure MDT board rounds are in place as a daily discipline for reviewing progress, goal achievement, and transition planning. |
| Step 5 | Step people down when goals are met. |
Diagram image
A5. Regularly review and monitor how intermediate care staff are utilised
| Step | Action |
| Step 1 | Measure staff utilisation rates: the amount of time spent in direct contact with people being supported. |
| Step 2 | Where utilisation is low, conduct a deep dive to understand causes — for example, skills and competency gaps, excessive administrative time, or a mismatch in resource allocation across pathways. |
| Step 3 | Ensure the best use of different types of professionals in mixed teams by matching utilisation to need. |
Productivity impact
[Link to case study]