On the Bandwagon?

Government policy advocates ‘intermediate care’ and ‘care closer to home’. It aims to relieve pressure on acute hospital beds by enabling rehabilitation and recuperation to be provided elsewhere: in people’s own homes, specialist acute hospital wards, community hospitals or specialist care homes. The policy envisages plurality of provision to meet plurality of need (Health Service Circular [HSC] 2001/01, 2001/03, Secretary of State 2006). In practice, the policy is awry. In the wake of significant bed-number reductions, many acute hospitals operate bedoccupancy levels significantly in excess of the recommended 82%. Yet such pressure on beds hinders infection control. It contributed to at least 33 deaths, from Clostridium difficile, at one hospital alone (Healthcare Commission [HC] 2006). It leads to vulnerable patients being moved from ward to ward for non-clinical reasons (HC 2006) and being sent home, unplanned, at 2 am (Barnes 2007). Acute beds have been closed prematurely, without alternatives. Rehabilitation beds, too, have been reduced greatly (British Geriatrics Society 2005). Astonishingly, of 310 community hospitals in England – typically providing rehabilitation and recuperation – 150 are now threatened with closure or cutback, on top of 3,000 beds already lost since 1999 (Stuart 2007). Yet the National Health Service Plan in 2000 had envisaged 7,000 new beds, acute and non-acute (HSC 2001/03), while government policy praises community hospitals (Secretary of State for Health 2006, Philp 2007). These contradictions suggest chaotic decision making, inconsistent with plurality of provision. Thus, an increasing article of faith is that virtually all non-acute rehabilitation beds can be closed in favour of home-based rehabilitation for everybody (for example, Suffolk West PCT 2005). This is clearly unbalanced. First, rehabilitation in the home is impractical for some people because of complexity of need, lack of space or family carers, family dynamics, or requirement for heavy rehabilitation equipment or continuous assessment and observation (for example, O’Connor et al 2006). Second, this over-simple approach, together with indiscriminate use of ‘care pathways’ and ‘payment by results’, suits people with more straightforward rehabilitation needs. It discriminates against those with complex, less uniform needs, characteristically older people with underlying multiple pathology now overlain by a major event, such as a fall, an infection, a stroke or a heart attack (for example, O’Connor and Neumann 2006). Third, the evidence anyway remains unclear about the cost-effectiveness of intermediate care and other health care, such as ‘Evercare’, in the home (for example, Anon 2005, Gravelle et al 2006). In summary, intermediate care should be used to enhance and readjust the balance of rehabilitation services, not be deployed as a Trojan horse to eviscerate them. The Audit Commission (2000) warned against the latter. One size does not fit all. If the occupational therapy profession rightly embraces the positives of intermediate care, it should equally disown the fashionable, but meretricious, bandwagon threatening plurality of rehabilitation provision.