The problem
Although many systems demonstrate positive relationships and shared objectives, these do not always translate into sustained commitment to improvement and investment. Intermediate care systems have evolved organically, which supports local adaptation but has often led to operational silos and fragmented planning. Establishing a clear strategic focus on improving the effectiveness of intermediate care will help to drive collective action.
Hospital discharge issues frequently dominate, diverting attention from step-up recovery, rehabilitation, and reablement that would prevent deterioration to the point where a person would need admission. Leadership continuity has been raised as a significant issue by the Reference Group, and shared local accountability is particularly difficult when there are multiple competing priorities, staff shortages, funding pressures, and persistently high volumes of demand.
Voices from stakeholders
“We have worked really well to get close to a new model, but then a key person left. There wasn’t the same commitment, and we ended up back at square one”
“I often feel accountable for intermediate care, but I don’t always have the power to make the changes needed”
“We have really good relationships at the top. We have a lot of good intentions and an ambition. But when there’s money involved, that’s where the big hurdle is”
Actions
B1. Develop a long-term strategic vision for intermediate care
| Step | Action |
| Step 1 | Agree across the partnership what needs to change and why — building a shared understanding of the gap between current performance and productive intermediate care. |
| Step 2 | Establish a shared vision and service model that consistently prioritises rehabilitation, reablement, and independence. |
| Step 3 | Embed the vision and service model in organisational strategies and BCF plans, to support resilience in response to changes in personnel. |
| Step 4 | Communicate the vision and service model across all levels of all partner organisations |
12 A community rehabilitation and reablement model, NHSE, 2023.
A shared system ambition facilitates shared action towards a single goal. Intermediate care should form part of a wider community offer, and systems have been asked to integrate service delivery as part of the development of neighbourhood health.
B2. Agree a partnership framework
| Step | Action |
| Step 1 | Develop a joint Memorandum of Understanding (or equivalent) that defines expectations, responsibilities, and collaborative approaches for all partners. |
| Step 2 | Agree governance and accountability mechanisms — ensuring partners are held to account for their contributions. |
| Step 3 | Build in a presumption towards closer alignment and deeper integration, empowering managers with the authority to innovate collaboratively. |
B3. Establish a clear operating model for how leaders will work together
| Step | Action |
| Step 1 | Agree clear roles and responsibilities across all leadership positions. |
| Step 2 | Appoint an identified executive lead from a system partner to provide strategic oversight of the discharge process. In addition, appoint a single co-ordinator – a senior lead who acts on behalf of the system to ensure safe and timely discharge on the appropriate intermediate care pathway. |
| Step 3 | Embed appropriate governance within each participating organisation, providing the opportunity to influence strategy and operations |
B4. Agree system metrics focused on recovery and independence
Partners should agree on four core outcome areas as the foundation for their local system:
- Greater independence and monitoring overall outcomes for people
- Better experiences for individuals and care teams
- Timely access to intermediate care (from hospital and from the community)
- Reduced hospital admissions and readmissions
A clear mechanism should be established for direct feedback from people who use services, and their carers.
Recommended additional metrics include: average weekly cost of a package, intensity and duration of intermediate care, number of step ups, waiting times (referral to assessment, assessment to service), and alignment with ASCOF metrics and the Better Care Fund framework for 2026 to 2027.
13 Hospital discharge and community support guidance - GOV.UK
Productivity impact
[Link to case study]