Overview
Prior to the COVID-19 pandemic, Halton’s intermediate care provision was delivered through several separate services. These included the Rapid Access Rehabilitation Service, a Capacity and Demand Team, falls prevention team, hospital discharge teams and a Frailty team. While each service provided valuable support, they operated largely independently.
The onset of the pandemic created an urgent need for greater coordination and responsiveness across health and care services. As a result, these teams began working more collaboratively than ever before, demonstrating the benefits of a more integrated approach.
The fragmented structure of intermediate care services limited flexibility and made it more difficult to respond effectively to fluctuations in demand. There was an opportunity to create a more streamlined, responsive system that would improve patient flow, enhance outcomes, and make best use of workforce capacity.
Action
In December 2021, a comprehensive review of intermediate care services in Halton was undertaken. Following this review, services were formally integrated into a single model: the Halton Intermediate Care and Frailty Service.
Key elements of the redesigned model included:
- A Single Point of Access (SPA)
All referrals for Pathway 1, Pathway 2 and urgent care response are now coordinated through one central access point, simplifying the referral process and improving response times. - Strong Partnership Working
The service is delivered collaboratively by Halton Borough Council and North Cheshire and Mersey NHS Foundation Trust. Ongoing partnership is supported through regular Steering Group meetings, ensuring shared oversight, continuous improvement, and alignment across organisations. - Flexible Workforce Deployment
A core feature of the model is the ability to deploy therapy and social care staff flexibly across different care settings based on demand. This includes bedded intermediate care services, reablement services, urgent community response, and hospital discharge teams. This flexibility is underpinned by robust demand analysis, allowing resources to be matched effectively to patient need. - Relationship Building
Building trust and strong working relationships across organisations was identified as critical to the success of the transformation and remains a key focus.
Outcomes
The integrated and flexible model has delivered several positive outcomes:
- Improved Responsiveness:
The service can respond more effectively to fluctuations in demand through dynamic workforce deployment. - Positive Staff Feedback:
Staff have responded well to the model, valuing the collaborative approach and increased flexibility. - Capacity and Activity:
The service currently supports:- Approximately 65 individuals within the reablement caseload
- Up to 25 individuals through urgent care response
- 19 intermediate care beds (increased to 25 beds in January 2026)
- Adaptability in Practice:
When bed capacity increased to 25 in January 2026:- Urgent response staff were redeployed to support the expansion
- 22.5 hours of occupational therapy capacity were allocated from the reablement team to ensure holistic care for patients in beds
This demonstrates the model’s ability to adapt quickly while maintaining quality and continuity of care.
The Halton Intermediate Care and Frailty Service represents a successful transition from fragmented provision to a cohesive, integrated model. By embedding flexibility, strengthening partnerships, and focusing on patient-centred care, the service is better equipped to meet the evolving needs of the local population.
Peers to Contact
Debra Coburn: [email protected]
Joanne Furmedge: [email protected]
Victoria Gleave: [email protected]
Louise Hall: [email protected]