View from the front line: redesigning care

Catherine Smith is a senior physiotherapist and foundation trust governor at Luton and Dunstable Hospital foundation trust

I am based in medicine for the elderly and am also the access, flow and workstream lead for our emergency services pathway redesign project. One reason I wanted to get involved with the redesign was that, as a physiotherapist, one of my biggest frustrations is a lack of joined-up thinking and partnership work.

Both in health and social care, decisions frequently appear to be made from a sector or organisational perspective and for short-term financial reasons. Yet the consequences do not seem to be thought through. Cutting a falls service might seem to save money but lots of evidence shows a team like that can prevent admissions and free bed capacity and the resource spend that goes with it.

The project tries to be as inclusive as possible and take a broad view of the emergency services pathway rather than just look at what we do here. We have planned a stakeholder workshop day and have sent invitations to primary care, the GPs and social services so that we can try to engage them in helping us to redesign our systems.

One challenge of working with older people is their often complex set of clinical needs. That requires a flexible range of services. But because we have two local PCTs, when it is time for patients to be discharged their entitlements depend on which GP they are with. You can find yourself wishing they went to another practice where more suitable care is available.

Many more older people are now being discharged from hospital needing social care packages. If they had a little extra rehabilitation in the community - occupational therapy and/or physiotherapy - it could improve their independence and reduce the level of need.

But because of their postcode we are not allowed to refer some patients, who fit the rehabilitation criteria, for the care package that we can see they will probably need for the rest of their lives. Instead we have to refer them first to intermediate care, whether it has the capacity to take them or not.

When I used to work at the day hospital we were treating two patients living almost opposite each other. Then funding arrangements were changed and because these patients had different GPs one could carry on attending but we had to tell the other he could not come any more. Trying to explain that was embarrassing.

It is just nonsense. Access to treatment and services should not depend on where you live or which GP practice you happen to be registered with.

National director for older people Ian Philp produced Recipe for care - not a single ingredient early in 2007. It was a great report, highlighting the importance of health and social care partnerships.

The responses it prompted on the special interest group website for physiotherapists working with older people, however, pointed to widespread service closure for want of funding and shared my concerns about the lack of joined-up thinking.